The Eclipse of the State Mental Hospital: {Policy, Stigma, and Organization.

By George W. Dowdall (New York: State University of New York Press, 1996. xiv plus 262pp. $21.95/paperback).

Many historians, including Ellen Dwyer, Gerald Grob, David Rothman, and Nancy Tomes, have produced excellent studies of the formation and development of mental institutions in the United States from the early 19th through the mid 20th centuries. George Dowdall's sociological work nicely complements these historical studies. He views state mental hospitals as "maximalist organizations" that have long lives while changing very little. His fundamental question stems from organizational theory: how have state mental hospitals, once born, resisted change in their basic forms and structures and had low mortality? Dowdall focuses on the single institution of the Buffalo State Hospital from its founding in 1872 to the present, although he occasionally presents comparative data on other state mental hospitals during this time.

A unique aspect of this work is the variety of methods Dowdall brings to bear on his question. One is event history analysis, a statistical approach that assesses the variables that account for the timing of when states first established mental institutions. Here, Dowdall finds that the number of physicians and level of urbanization, but not immigration or industrialization, account for when states opened their first mental hospital. A second is an interesting analysis of many photographs from the life course of the hospital. He uses this visual record both to show how little everyday life on hospital wards has changed over time and to contrast the visual with the written record of hospital life. For example, he counterposes the enforced idleness, compelled activity, and passivity displayed in the photographs with the optimistic view of occupational therapy found in the hospital's annual reports. A third method is the use of economic time series analysis of short- and long-term changes in admission rates to test Harvey Brenner's assertion that economic downturns produce increased rates of hospital admission rates. Dowdall, in contrast, finds no relationship between economic fluctuations and admissions in any historical period he surveys. Finally, much of the book uses evidence taken from sources that include an exhaustive reading of the hospital archives, newspaper articles, and legislative hearings about Buffalo State Hospital. This record shows both the great resistance to change in the hospital's structure and everyday life between its founding and the early 1960s and the fundamental changes the hospital has undergone since the latter date. Dowdall attributes the wide-ranging change in the state hospital since the 1960's to pressures to conform with external accreditation standards. In recent years, state hospitals have lost their central place in mental health policy and have had much smaller populations than in the past. Nevertheless, they continue to absorb a very large proportion of state mental health budgets because they remain the caretakers of last resort for the most serious and disruptive persons with mental illness.

Social historians will find much to praise and elements to criticize in this book. The variety of methods the book employs represents perhaps its strongest aspect. Another contribution is Dowdall's use of organizational theory to connect the internal structures of hospital life to its external environment. The weaknesses of the book in part stem from its strengths. The great variety of methods makes this work seem somewhat eclectic. They provide good analytic breadth but lack the depth typically found in historical case studies of a single institution. Finally, Dowdall (whose concern with Buffalo State Hospital stems from his period of employment there) does not make a strong case for any particular interest of this institution, aside from its typicality. Overall, however, Dowdall's book should appeal to sociologists and historians of the mental hospital both for its multiple methodological strategies and its theoretical analysis of hospital structures and social change.

Allan Horwitz Rutgers University