Asylum: The Complex and Controversial Story of Mental Institutions in the U.S.A.

Asylum: The Complex and Controversial Story of Mental Institutions in the U.S.A. Co-produced by Sarah Patton and Sarah Mondale (Washington, D.C.: Stone Lantern Films, 1989).

In a graphic and absorbing way, Asylum brings to the viewer the essence of Americans' unresolved attitudes about the mentally ill. For more than two centuries, Americans have waged a debate about the fate of the mentally ill, and Sarah Mondale and Sarah Patton, producers for Stone Lantern Films, capture that ambivalence through careful selection of photographs and case study films from the 150-year-old archives of the now defunct St. Elizabeths Hospital in Washington, D.C. The intensity of the historical issues surrounding the origins of the asylum is dramatically conveyed in the on-camera debate of Gerald Grob of Rutgers University and David Rothman of Columbia University, the most prominent scholars on these issues.

Footage of the homeless mentally ill in a city park and the opening volley between Rothman and Grob set the scene in the first few minutes of this splendidly edited and moving film. How and where do we care for the insane? Is there once again a need for the asylum?

In colonial times the mad were seen either as bedeviled or touched by god, but largely left alone. As political, social and economic change intensified in the mid-eighteenth century, neighborly tolerance diminished and jails, pesthouses, or unheated attics and sheds increasingly became the habitats of the mad. Beginning in the early nineteenth century and prevailing for another century and a half, the publicly-supported asylum provided care and treatment for the mentally ill. Today, as a result of the deinstitutionalization movement of the 1960s and 1970s, the majority of seriously mentally ill people once again are left alone to populate the streets. Rothman argues from a civil libertarian point of view, although his position is not as extreme as that of Thomas Szasz who claims that the existence of an asylum itself is an abuse and has no discernible use except to enforce conformity and control deviance. Rothman is willing to concede that the asylum served a very few for a decade or so, but the asylum's quick deterioration resulting in incarceration against one's will left it with no redeeming qualities throughout most of its history. Rothman admits his disappointment that American society has not delivered quality services for the poor and chronically mentally ill, but he nonetheless would eschew the asylum because "we have 150 years of failure." He advises even now that "we invest completely, thoroughly, and diligently in alternatives."

Grob, on the other hand, presents a multifaceted case for the asylum. He points out the reformist origins of the asylum, noting that the nineteenth-century asylum movement was a reaction to earlier unsuitable and inhumane incarcerations of the mentally ill. From its inception, however, the asylum encompassed the dual purpose of offering a safe place for custodial care for the chronically ill and a therapeutic environment for those deemed curable.

As American society became more industrialized, urbanized, and bureaucratized, the numbers of institutionalized chronically ill multiplied geometrically. Doctors, overwhelmed by sheer numbers of patients, and staffs, overworked and lowly paid, struggled simply to maintain some semblance of order. By the end of the nineteenth century, the therapeutic function of the asylum had lost ground to the custodial. But, according to Grob, the asylum was not necessarily an overall failure. In the late nineteenth century, overcrowding may have reflected the inability of a rapidly changing society to monitor the effects of those economic and social forces, but it also suggests the ability of working-class families to devise ways to make use of the custodial functions of the asylum in a society that did not yet provide nursing homes, sanitaria, or widely available and affordable medical care. In the twentieth century, even in the face of the emergence of psychodynamic therapies, asylum doctors continually sought new therapies for the chronically ill. Shock therapies and surgical interventions quickly fell by the wayside, but were indicative of the continuing therapeutic activism fostered largely in the overcrowded asylums. Indeed, it was asylum doctors in the 1950s who most readily saw the benefits of the psychoactive drugs for their patients.

Deinstitutionalization was inevitable. Grob reminds us, however, as he has in many forums, that for some patients the asylum will always be necessary as the haven, the structured environment, the isolation from the world with which they cannot deal.

The makers of this film rightfully claim that Asylum is indispensable viewing for all mental health professionals and policy-makers, psychiatric nurses and students, organizations concerned with the homeless, advocacy groups, as well as patients and their families. Asylum illustrates that there are no easy answers, that we have erred far too often in our zeal to find the one true answer to a complex, controversial, and perplexing social issue, that a knowledge of history must inform policy-making, and that simply providing more resources does not address the heart of the problem. Americans' attitudes about the mentally ill and about the asylum have been shaped by the prominent and by the masses and those attitudes, and thus policy, have changed over time in reaction to political forces and to pressures from ordinary people. We have not yet understood the many uses of the asylum at its best; Asylum starts us on our way, however belatedly.

Constance M. McGovern University of Vermont