America, somewhat later, had its own “father of psychiatry,” Dr. Benjamin Rush, who in 1812 would write the first psychiatry textbook to be printed in the United States: Observations and Inquiries Upon the Diseases of the Mind (Penn Medicine, 2017a). In addition to practicing medicine, Rush was a signer of the Declaration of Independence and a civic leader who was outspoken in his opposition to slavery and support of education – including the education of girls (University Archives and Records Center, 2022). Some of Rush’s voiced beliefs were in conflict with his actions, however, as he is reported to have engaged in slave ownership for a period (Dickinson College, n.d.). Rush’s progressive views, limited as they were, extended to the treatment of patients with mental disorders.

1.3.1 The Creation of State Hospitals

By the early 1800s, American communities following in European footsteps had developed asylums as well. The higher-end asylums followed the lead of the French doctor Pinel, engaging in what was called moral treatment of patients. Benjamin Rush was a practitioner of this approach. Moral treatment for people with mental illness was based on the idea that ill patients could become well if they were treated kindly, in ways that appealed to the supposed “rational” parts of their minds.

Moral treatment specifically rejected the harsh treatments that had previously been used to respond to mental disorders, as well as the moral judgment or thinking that an ill person was somehow “bad” (Plested, 2017). Instead, the moral approach idealized peace, quiet, and seclusion. American asylums, as opposed to the dungeons of 17th century Europe, were intended to provide this peaceful atmosphere, in hopes of curing their inhabitants (D’Antonio, n.d.).

The active treatments for mental illness offered in American asylums remained very limited in the 1800s. Treatments still included older approaches such as bloodletting, but Dr. Rush himself introduced some new innovations as well. He created a “tranquilizer chair” (figure 1.7) and a gyrator, which would spin restrained patients, in order to encourage better circulation of their blood. The tranquilizer chair especially, though obviously troubling by today’s standards, was a step forward in that it was intended to calm patients by restraining their heads and bodies without the use of a straightjacket (Penn Medicine, 2017b).

Figure 1.7. Benjamin Rush’s tranquilizer chair was intended to calm patients by restricting their movement, as an alternative to using a straightjacket to control the patient.

By the mid-1800s, though more expensive private asylums had incorporated moral treatment approaches, many poor American patients with mental disorders still languished in jail-like facilities (D’Antonio, n.d.). This state of affairs inspired school teacher-turned-reformer Dorothea Dix (figure 1.8) to push for change, specifically the establishment of what would be known as state hospitals. State hospitals were psychiatric facilities, in the model of the asylum, funded by the government to serve the public.

Figure 1.8. Dorothea Dix, a reformer and advocate for poor people and those with mental disorders, was instrumental in creating mental hospitals, known as state hospitals, in America.

Dix had reportedly visited jails with the intent of religious outreach, and she became concerned to realize the extent of mental disorders among people who were incarcerated. Recognizing this as a widespread problem in America, Dix traveled throughout the country during the 1850s and 60s, offering testimony to state legislatures and Congress, urging lawmakers to move people with mental disorders out of jail-like institutions. Dix proposed that states create special, publicly-funded hospitals to house this population. These new facilities imagined by Dix would be dedicated to treatment for those with mental illness, and she believed they offered the opportunity for better treatment, and even cures, for many patients. Dix’s advocacy contributed directly to the creation of more than 30 state hospitals. By 1870, nearly every state had a public hospital or asylum, built on the principles of moral treatment (D’Antonio, n.d.; Parry, 2006).

Dix’s advocacy and results were impressive, especially considering that her work preceded passage of the 19th Amendment allowing women to vote by some fifty years. However, over time it became clear that the new state hospital facilities promised more than they were able to deliver. State hospitals were indeed an improvement over previous facilities, but they offered no actual cure to most of their inhabitants (Tracy, 2019). In fact, the hospitals were increasingly used to house additional populations – such as the elderly or people with disabilities – who needed state-funded care, but who were not moving toward “recovery.” The state hospitals began to exceed their capacity and their limited resources, full of patients likely needing care for their entire lives (D’Antonio, n.d.).

By the late 1800s, state hospitals were plainly showing their overwhelm. They were overcrowded, increasingly filthy and offered very little in the way of actual treatment to their residents. (Spielman, Jenkins & Lovett, 2020; Farreras, 2023). The practice of institutionalization, the segregation and confinement of  people with disabilities or mental illness in facilities rather than integrated into communities, was firmly entrenched. (Spielman, Jenkins & Lovett, 2020) Ultimately, the new hospitals championed by Dix were simply the latest way to confine and remove this population that was unwelcome in American society.

Stories of the horrors at state hospitals abound – and could fill an entire textbook. One example, the Willard Psychiatric Center, originally called the Willard Asylum for the Insane, first opened in 1869 and remained open for 130 years (New York Heritage, n.d.). At Willard, in upstate New York, reported “treatments” included submerging patients in ice-cold baths – while wintertime temperatures in the facility were said to be cold enough to freeze a glass of water left on a table overnight. (Willard Psychiatric Center, 2009; Spielman, Jenkins & Lovett).

Willard was not alone in its miserable treatment of patients; rather it was typical of state institutions at the time. Reports on other similar hospitals reveal that people were often treated cruelly – with reported beatings, sexual abuse, and experiments performed on unknowing residents (Brown, 2021). Since every state had built an institution for its mentally ill and/or disabled residents, nearly every state has a history of an abusive institution that existed for decades, at least, extending into recent history. Some of these histories remain more obscure than others, with residents often not able to express and publicize their experiences.

Oregon had its own infamous institutions, including the Fairview Training Center. Over the course of its life, Fairview confined thousands of people, from young children to the elderly, with a range of disabilities that often included mental disorders. Fairview opened in 1908 as “an institution for the feeble-minded, idiotic, and epileptic,” with 39 “inmates.” It eventually became Oregon’s largest institution, housing 3000 residents at its peak. Fairview residents were restrained, whipped, drugged, and locked into small cages. Disabled children often entered Fairview and remained confined there for their entire lives. Thousands of Fairview residents endured forced reproductive sterilizations that continued to occur through the 1970s (James, 2015). Watch the video in figure 1.9 to hear from Fairview residents themselves who were victims of forced sterilization, which is discussed further in the Spotlight in this section.

Figure 1.9. Eugenics: In the Shadow of Fairview [OPB Video]. This short video clip from the longer documentary “In the Shadow of Fairview” highlights the story of the over 2600 Oregonians who underwent forced sterilization due to their disabilities while at or trying to leave Fairview Training Center.

Oregon’s Fairview Training Center remained operational (and overcrowded) well into the 1980s, despite advocacy by the oppressed residents, sanctions for mismanagement and abuse of the people it housed, and even a U.S. Department of Justice investigation in 1985. Fairview finally began to downsize in the 1980s, but it stubbornly remained open until 2000. The institution housed 1500 residents in 1986, and was down to 300 by 1996 (Drummond, 2000). For more information on Oregon institutions, see the Spotlight in this chapter on the Oregon State Hospital.

1.3.3 Racial Segregation in Institutions

Given that institutionalization of people with mental disorders took place during a time of widespread racial segregation in America, there were state hospitals, or sometimes parts of hospitals – such as basements – dedicated to housing Black patients. Though the Civil Rights Act of 1866 required state hospitals to accept Black patients, many completely refused to do so, and where they were admitted, they were segregated from white patients (Swenson, 2017). Virginia’s “Central Lunatic Asylum for the Colored Insane,” later known as Central State Hospital, was filled in the late 1800s with Black patients housed in primitive and abusive conditions. All of the women in the facility were guarded by men, based on the thinking that the women needed guards with enough strength to properly control them. Many of the Central State residents had been deemed mentally ill and fit for institutionalization based on nothing more than accusations by racist whites, unhappy with the free status of former slaves. Some Black residents were declared insane based on their simple desire to be free (Brumfield, 2021). Indeed, during the period of slavery, Black people had routinely been found mentally ill simply for desiring or attempting to escape enslavement (Swenson, 2017).

Patients in any early American psychiatric institution rarely received humane care or treatment for mental illness, or whatever disorder had led to hospitalization, but this failing was especially pronounced for Black patients. These patients endured particularly dehumanizing treatment based on race. In records from the Central State Hospital, detailed notes about patients were almost always summaries of their “usefulness” – that is, their ability to work. Formerly enslaved people both in and out of institutions were considered valuable only to the extent they could be part of a planned cheap labor force in the post-slavery era (figure 1.11; Swenson, 2017).

Figure 1.11. This photo of Black women in the Central State Hospital shows them engaged in “diversional occupation.”

1.3.4 Treatment of Mental Disorders in the 1900s

During the mid-1900s, treatments offered to patients in state hospitals had expanded beyond bloodletting, but these treatments remained in experimental stages. Mentally ill and disabled people in institutions suffered the burden of trial and error. Modern electroconvulsive therapy (ECT), which involves passing small electric currents through a patient’s brain, is performed under anesthesia with safeguards in place. ECT creates changes in brain chemistry that have been highly effective in treating conditions such as severe depression (Mayo Clinic, 2018). The original version of this treatment, however, known as electroshock therapy, induced seizures with large amounts of electricity. The procedure was done without anesthesia, and it was terrifying and dangerous. A patient described the experience of electroshock therapy at the Missouri state hospital in 1957:

Patients were generally on [electroshock] treatment twice a week . . . . Begging, pleading, crying, and resisting, they were herded into the gymnasium and seated around the edge of the room.

Between them and the shock treatment table was a long row of screens. The table on the other side of the screen held as much terror for most of these patients as the electric chair in the penitentiaries did for criminals… In order to save time, one or more patients were called behind the screen to sit down and take off their shoes while the patient who had just preceded them was still on the table going through the convulsions that shake the body after the electric shock has knocked them unconscious.

One attendant stands at the head of the table to put the rubber heel in their mouth so they won’t chew their tongue during the convulsive stage. On either side of the table stand three other attendants to hold them down . . . (Missouri State Archives, 2003)

Early brain surgeries to cure mental disorders were, likewise, an ill-advised and often devastating treatment. Modern surgical approaches to brain disorders are very promising in certain cases, such as severe epilepsy, but the practices and goals in these early days were quite different. Lobotomies, where part of the brain would be removed with a goal of managing or curing mental illness, were performed on patients up until the 1950s in America (Tracy, 2019).

Rosemary Kennedy, the sister of eventual President John F. Kennedy, was subjected to a lobotomy as a young woman (figure 1.12). Rosemary’s father, Joseph Kennedy, reportedly ordered the lobotomy, which occurred in 1941 when Rosemary was in her early 20s. As a result of the surgery, Rosemary was left seriously disabled (John F. Kennedy Presidential Library and Museum, n.d.). It was believed that Joseph Kennedy’s request was motivated by Rosemary’s disruptive behavior that caused the family embarrassment and threatened the Kennedy males’ political careers (Gordon, 2015). Rosemary was influential largely because of the impact her surgery and ensuing disability had on her powerful and famous siblings; she herself was hidden from public view and was cared for in an institution away from even her family for most of her life.

Figure 1.12 is a photo of Rosemary Kennedy, who was given a lobotomy by doctors at the direction of her father, Joseph Kennedy (John F. Kennedy Presidential Library and Museum, n.d.).

Perhaps the most famous portrayal of a lobotomy was that involving Randle McMurphy, the fictional hero of Ken Kesey’s 1962 anti-psychiatry novel, One Flew Over the Cuckoo’s Nest, set at an Oregon psychiatric institution. McMurphy, who fakes mental illness to avoid criminal responsibility, ends up both inspiring his fellow hospital residents and suffering along with them. Kesey’s book came out as civil rights activists were questioning all aspects of establishment and authority in America – including the state hospitals. The book and the 1975 film, which also depicted a horrifying view of ECT as more torture than treatment, were award-winning as pieces of art, but certainly left a broad group of Americans questioning the value and ethics of psychiatric hospitalization and treatment (Moffic, 2014).

1.3.5 Mental Disorders in Modern Times: the Rise of Institutional Treatment: Licenses and Attributions

“Mental Disorders in Modern Times” by Anne Nichol is licensed under CC BY 4.0.

The subsection “Creation of State Hospitals” within “Mental Disorders in Modern Times” is adapted from:

•  “Mental Health Treatment: Past and Present” by R. M. Spielman, W. J. Jenkins & M.D. Lovett, Psychology 2e, which is licensed under CC BY 4.0.
• “History of Mental Illness” by Ingrid G. Farreras, Noba Textbook Series, Psychology, which is licensed under CC BY-NC-SA 4.0.

Modifications by Anne Nichol, licensed under CC BY-NC-SA 4.0, include substantially expanding and rewriting.

Spotlight: Carrie Buck and the Practice of Eugenics by Monica McKirdy is licensed under CC BY 4.0.

Figure 1.7. “Benjamin Rush’s Tranquilizing Chair” by National Library of Medicine is in the Public Domain

Figure 1.8. “U.S. Library of Congress DIX, DOROTHEA LYNDE.” by US Library of Congress is in the Public Domain

Figure 1.9. “Eugenics: In the Shadow of Fairview” [clip of Season 15 Episode 1] by OPB is included under fair use.

Figure 1.10. Carrie and Emma Buck at the Virginia Colony for Epileptics and Feebleminded by  A.H. Estabrook before the Buck v. Bell trial in Virginia, is in the Public Domain.

Figure 1.11. Photo of Black women in the Central State Hospital is in the Public Domain.

Figure 1.12 Photo of Rosemary Kennedy, included under fair use.