When I was employed at Western State Hospital first as a therapist, later as a department manager, I observed how vast the hospital was, how small the patients’ world was, and the effect their living spaces had on their behavior.
One can often hear cacophony even before opening the door to the wards. Once inside, one encounters a fishbowl-like, tiny nursing station ringed by glass on all sides. In the central day room, metal chairs and stools are bolted to the floor. The floor itself is bare tile. The walls are painted concrete. Smaller rooms off to the sides house small lounge areas, with heavy furniture and televisions covered by plexi-glass. In addition to the yelling, there is often music playing and televisions blaring. Patients pace to and fro. Fights and assaults are common, often occurring over food.
In the old days, the people who lived in what were termed “insane asylums” were referred to as “inmates.” Despite the presence of doctors and nurses, this term applies to forensics patients now more than they ever did before. Many forensics patients told me that they missed being in prison and would choose prison over the hospital if they had a choice, because prison offered them more freedom, privileges and comforts than the hospital does.
Photographs taken throughout the 20th century reveal a starkly different reality than the one that exists today. One photograph from the 1920’s shows a ward with beautiful hardwood floors, potted plants, curtains, area rugs and a baby grand piano. Other photos depict galas where patients and medical staff danced together (they even had a conga line!), planted crops, had a baseball league, raised livestock, and tended a mercantile store that sold hand-made products built by patients including intricate wicker chairs and Adirondack chairs. Among other projects created by patients, there was a world-class sunken garden with terraced waterfalls and a golf-course.
A large, bronze plaque dedicated to occupational therapy rests beside the bare concrete building foundation of the old hospital like a tombstone; it mentions the farm, which officially closed down in 1965. At the base of the hill below, the feral, overgrown remains of the orchard planted by occupational therapists and patients a hundred years ago. It still produces fruit, literally the fruit of our efforts to revive and restore human beings to a state of wellness.
Occupational therapy became organized as a distinct profession in 1917, but its roots go back further, to the moral management movement of the 19th century. A French psychiatrist, Philippe Pinel, was one of the early proponents of moral management (also called moral treatment) who posited that humane treatment of the mentally ill could cure their condition. Quakers both in England and America further developed Pinel’s methods by providing routines, physical labor, and other activities in order to help people thrive. Previous to this era, it was believed that mental illness resulted from criminal tendencies, a lack of willpower and other hypothesized etiologies that tended to blame the sufferers.
Before the 19th century, “treatment” of mental illness consisted of isolation, deprivation, and chaining people to walls and floors without food, water, heat or sanitation. The term “bedlam” with its connotation of chaos, disorder and pandemonium is derived from the colloquial name for the infamous Bethlem Hospital in London, where at one time upper class members of society would pay an admission fee to gawk at patients, and were even offered sticks to prod the inmates in order to provoke a reaction from them.
Moral management was reaction against these inhumane conditions. The movements’ founders were inspired by their Quaker religion, believing they had a moral obligation for the proper care of people with mental illness. What was considered “proper” differed from modern concepts of appropriate care and treatment. Interwoven with the desire to treat people with care and kindness was a paternalistic impulse that included mandatory religious observation, and did not honor choice, freedom or individuality the way we do in the 21st century. Like in other eras (including our own), moral management-inspired doctors and psychiatrists had clear ideas of what was “best” for people with mental illness that left little room for argument or dissent.
The success of moral management was difficult to gauge, since scientific methods were in their infancy in the 19th century, and the concept of “cure” was a vague umbrella term that could have numerous meanings. Then as now, treatment providers and leaders of institutions were under pressure from funding sources and others to prove the efficacy of their treatments. Therefore “cure rates,” were sometimes inflated in the same way that statistics are manipulated today in order to offer a more favorable impression. “Cure” was sometimes defined by how many people were discharged from asylums, not accounting for their condition before, after or during their stay.
It’s fair to say that our concept of “health care” would be as alien to the proponents of the moral management movement as their notion of cure is to us. Along with their distinctive combination of meaningful occupation and hard work, the Quakers had a grasp of the potential healing or the toxic effects of environments—albeit in a rudimentary way. While modern social philosophers and scientists offer belated arguments about the deleterious effects of stress and the influence of the environment on the human body, many the 19th century physicians believed this connection was obvious and it was a taken for granted aspect of their thoughtful treatment planning. It begs the question: are we just discovering this connection between stress, the environment and health, or are we simply acknowledging and paying heed to it after forgetting what was already known 150 years ago?
Chief among these mental health environmental planners was Dr. Thomas Story Kirkbride, a Quaker psychiatrist who was known for his creation of a concept for the ideal “insane asylum.” Today, the words insane asylum conjure up images of people locked away in squalor or abused by orderlies in white coats. This stereotype of the insane asylum (popularized by books and films like One Flew Over the Cuckoo’s Nest, and others) is a perversion of Dr. Kirkbride’s philosophy (known as the “Kirkbride Plan”) which reached its zenith in the 1950’s, when mental hospitals became little more than warehouses for people with mental illness.
In the 20th century, mental hospitals and psychiatric treatments were designed to pacify the mentally ill and protect society from them. Many have argued that this pacification was merely a form of social control of societies’ outcasts, rather than an attempt at treating people. In Kirkbride’s day (Dr. Kirkbride lived from 1809-1883), the asylum was designed as a kind of micro-utopia, set apart from and free from the influence of urban society. It was designed to save people from the ills of society and not the other way around.
His plans specified that the asylums were to be located no closer than two miles from the nearest city or town. In the era before automobiles, this was a considerable distance. Buildings designed to Kirkbride Plan specifications were precisely situated to allow for fresh air, sunshine, and views of nature from patients’ bedroom windows. They were expected to have the most modern forms of heating, plumbing, and water sources (Kirkbride even specified the water temperature of the boilers used to provide steam heating!) With a population capped at no more than 250 patients, Kirkbride was mindful of the ill effects of crowded spaces. While access to the healing qualities of nature was emphasized, Kirkbride was not advocating a spartan, ascetic lifestyle.
In the Kirkbride Plan, outdoor space was just as meticulously designed as indoor space. He partnered with the most prominent landscape architects in America (including Frederick Law Olmsted, who had just designed Central Park in New York City). Kirkbride’s minimum design requirements called for at least 50 acres of grounds, which not only included arable land for planting food crops, but groves of trees, trails and walkways that were designed solely for aesthetic enjoyment and therapeutic benefit.
The Kirkbride Plan and Olmsted’s aesthetic choices were the product of Victorian-era ideals of refinement, and pioneered the concept of public space and open, universal access in a way that transcended social status, class and disability. Kirkbride’s vision called for landscape design that could not only be utilized by people immersed in it, but also fully appreciated by patients who, by dint of the severity of their symptoms, were only able to enjoy these landscapes by looking out of their windows. As with the photograph of the Western State Hospital dating to the 1920’s, Kirkbride also believed in bringing the outdoors in, with large, potted plants.
Simply put, Kirkbride and his 19th century contemporaries believed that disordered minds were the product of disordered societies and chaotic cities. Their ideal of the insane asylum (which, for complex reasons, many of them economical, was never fully realized) was a carefully planned space where broken minds could—and were fully expected to—heal. The insane asylum was run by a father figure, the superintendent, who oversaw patients’ linear and progressive recovery. While it was simplistic and perhaps even rigid in its religious austerity, moral treatment honored human needs for good food, clean air, meaningful work, exercise and healthy stimulation. Most importantly, it re-created a microcosm of society, but one which was more accepting, understanding and humane than the world that the “inmate” had left behind.
The insane asylum can be contrasted with the psychiatric or “behavioral health” hospital of today, whose primary emphasis is not on healing, but temporary stabilization. Though the concept of rehabilitation did not exist in the 19th century, many of the activities, and the balanced connections between work, leisure, physical exercise and intellectual pursuits were viewed by the godfathers of moral treatment as absolutely fundamental to the practice of normal, healthy human living. In my experience of working at several mental hospitals, rehabilitation activities are widely viewed as unimportant privileges or extra-curricular in nature--essentially, an afterthought to the "real" therapy of psychiatric medication.
By treating fresh air, exercise, adequate stimulation and meaningful activity as unnecessary, inhumane conditions prevail, and whether the person locked inside these walls is called an inmate or a patient, they are inevitably encouraged to be a passive recipient of services. The bare walls, stupefying drugs, junk food and zombie-like TV screens do nothing to prepare them for any but the most impoverished life beyond the hospital walls. Although “safety,” is the mantra of the mental hospital administration, revenue—saving or generating—is their primary goal. The asylums of old were run by superintendents. Todays’ hospitals are run by CEOs and business executives. Health “care” has been reduced to matching data points with targets for efficiency and productivity and other quality or performance measures that the average patient would neither comprehend or desire.
At the ancient, government-run hospital where I worked, the unspoken truth is that while lip service is paid to rehabilitation, a criminal justice approach is the guiding principle. This approach warrants that patients are confined not to be rehabilitated, but to be punished. The easiest method of punishing people is to deprive them of the ability to meet their human needs.
All sorts of disingenuous reasons have been given over the years when I’ve asked why patients were never allowed to create and decorate the walls with artwork, why carpeting couldn’t be used in the wards to act as a sound dampener and create a more welcoming atmosphere, why staff were not allowed and encouraged to eat meals with patients—why even the most threadbare, anemic gestures for building community are forbidden. Only the most favored and privileged patients are even allowed to have some form of meaningful employment or have a hand in their own care. Even my efforts to allow a patient to wipe down the table where they eat with a damp washcloth were rebuffed.
Western is one of the oldest psychiatric hospitals in the country. At Wellfound, one of the newest, just a few miles away, one can view a stunning piece of state of the art structural engineering that meets every need dreamed up by a corporate boardroom, and little to no input from the patients and staff who must inhabit it. Here, I observed patients staring at massive TV screens hermetically sealed behind plexi-glass without bluetooth or other Wi-Fi or internet capabilities, thus exposing them to the wasteland of cable TV with no possibility for therapeutic activity.
While I saw patients watching female mudwrestling or the Jerry Springer Show with the volume turned up, many staff were completely disengaged, staring at the screens of their own phones. With few to no tools for therapeutically engaging with the patients, there was little else for them to do. The rooms designed specifically for rehabilitative purposes were far too small, unsafe and ill-equipped to use for the vast majority of therapeutic groups or activities. Just as with Western State Hospital at Wellfound basic human needs for space, for meaningful activity and interaction were treated as inconsequential and irrelevant rather than integral to their healing. It’s as though the institution’s designers and administrators hoped that patients recovering from acute episodes of mental illness would need nothing more than to eat, sleep and watch TV.
People are the products of their constructed and natural environments. If people are treated like dangerous animals, they will behave accordingly. Risk is often determined solely from an arbitrary list of objects to ban, rather than a clinically informed perspective. These lists are often developed based on the paranoid fears of the people who dream them up, or as a knee-jerk response to a single incident that occurred sometimes decades ago. These approaches are both punitive and counterproductive, and those who support them are often unable to articulate a coherent, lucid rationale for their application.
A more therapeutic approach would be to use the tools available to craft settings that promote serenity rather than chaos. An even better approach would be to design new hospitals with input from professionals who have experience and expertise in the therapeutic modification of physical spaces. Simple interventions like placing carpeting some of the concrete floors of the wards to act as both a sound dampener as well as a means to normalize the space, and thus reduce the tension and anxiety that often lead to assaultive behavior.
Placing patients’ art on the wall could create a sense of agency and ownership by allowing them to have a direct influence on how their living space is decorated. A simple innovation like placing a tablecloth over steel tables with rust and peeling paint could imbue a mundane activity with a sense of care and importance. Giving patients something to do, even something as simple as wiping down a table after a meal with a wet washcloth, could increase trust, and foster a sense of personal responsibility that is conducive to a faster recovery and discharge to a community setting.
Many of my past superiors have admitted unequivocally (albeit privately) that psychiatric hospitals are not healing places. But my experience has taught me that rehabilitative approaches—including therapeutic modification of the environment—are treated as a last resort, or at best a benign diversion for patients until their medications take effect and their symptoms stabilize. I find it fascinating that 19th century doctors and administrators figured out that carefully designed spaces and meaningful occupation are key to healing without access to any of the tools of inquiry we possess today.
Regardless of the tenacious persistence of institutionalized care and medicalization, the era of the psychiatric hospital is in its sundown phase. How could we expect significant restoration to occur on wards, units and nursing stations when these places have no resemblance at all to the lives lived by ordinary people and a quotidian existence? Medical and rehabilitation staff make a valiant effort to provide compassionate, competent care within the constraints of the systems they must operate in. The medicalization of mental illness has caused society to ignore the pursuit of wellness. Perhaps society would do well to re-envision the concept of the asylum not simply as a refuge from the ills of urban living, but as a model for the activities and environments needed to live well anywhere. Simultaneously, urban living spaces could be more livable through the reclamation and redesign of places that foster community building, personal wellness, and the human need for occupation.
While the tenets of moral management may appear quaint and unsophisticated today, they are increasingly being reinvented and applied by modern social planners seeking new ways to design livable spaces in the increasingly stressful and taxing urban environments inhabited by most people. They also find parallels in Scandinavian concepts like lagom and hygge, cultural lifestyle concepts that have made inroads into the therapeutic lexicon. We cannot and should not rewind our thinking in a nostalgic attempt to recreate the era of moral management, which had its drawbacks. However, we can learn from the humane and healthful methods it enacted and combine those with the understanding of human needs we have since accrued.
The evolution of these ideas are seen in the holistic perspectives of occupational therapy and its numerous ecological theories, which seek to support the human capacity for peace, joy, and healing through conscious adaptation of our work and living environments. The work of societies’ structural and social architects will not be finished until every human being can access a living space that is both desirable and health promoting, whether they are already well or in severe crisis.