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Personal Accounts: State Hospitals and Getting Stuck in a Train
Paul Kettl, M.D., M.H.A.
Psychiatric Services 2010; doi: 10.1176/appi.ps.61.6.552
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Dr. Kettl is education director at the Behavioral Health Service, Philadelphia Department of Veterans Affairs Medical Center, University and Woodland Avenues, Philadelphia, PA 19104 (e-mail: paul.kettl@va.gov). Jeffrey L. Geller, M.D., M.P.H., is editor of this column.

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I was eight, and I never laughed so hard in my life. My grandparents and my family went to a local amusement park with a miniature train for the children to ride around and around in a circle, with the parents standing alongside waving and waving.

My grandmother insisted on riding with us on the train, and we all thought she was a good sport, involved in the fun. The train stopped, and we all ran off, excited about our new experience—only my parents weren't looking at us, they were looking at the back of the train. My grandmother, a very stout German woman, was stuck. She had managed to get her legs and arms out of the train, but her large derriere was firmly lodged in the back of the miniature train car. My dad pulled and pulled, but my grandmother had her back end firmly encased in the bars at the entrance to the last train car. We all laughed and laughed, amazed that Grandma had her rear end stuck in the last car, and in my eight-year-old brain, I wondered a little if she would ever be able to get out. Finally, a carnival worker came by and pushed from behind as my father pulled from the front, and with the help of the worker, my grandmother broke free. We did other things that day, but few were as memorable.

It didn't occur to me at the time, but we were lucky to have my grandmother with us at the amusement park that day. Some time earlier, she had been discharged from a state hospital.

My grandmother's illness began gradually. She became less interested in things and less involved in family and church activities, which had been her life. Her illness continued to progress until finally she simply sat in a chair at home and stared. My aunt said, "She simply sat there and stared—all day."

My grandfather was determined that he would have "only the best" for his Tressy. He contracted with the psychiatrist in private practice in town to visit Tressy at our family's house. The psychiatrist made frequent visits, but according to my mother, he was drunk "half the time." He came by more often and then started my grandmother on medications, one after the other. She continued to sit and stare at the floor. Finally, "the best psychiatrist in town" said he could do nothing more for her and suggested that she go to the local community hospital.

Tressy went to the hospital for medical examinations and more treatments. Mostly, though, she sat and stared. That hospitalization passed, and she returned home. She was not eating much and was doing less. She continued to decline. Finally, the family doctor suggested that she go to the state hospital in the next town. "We didn't know what to do," my aunt said. My grandfather, who wanted only the best, finally agreed to have his Tressy admitted to the state hospital.

"When they took her, that was a low point," my aunt said. At the state hospital, she continued to sit with that same vacant look on her face. Then, a young doctor, according to my mother, suggested that my grandmother be given electroconvulsive therapy (ECT). After some discussion and more than a little hopelessness, the family finally agreed. "We didn't know what else to do," my aunt said.

When the next weekend's visiting hours came, "My mother ran down the hall and threw her arms around me," my aunt said. "I was never so happy to see anybody in my life." Grandma Tressy had a couple more ECT treatments and finally returned home. This time, though, she was active and eating. She resumed her habits of eating too much, regained weight back to her former obesity, but now none of us complained. Tressy was back and active in our lives and with her friends from church. As far as I know, she never had another episode of depression.

I did well in school, went on to medical school, and became a psychiatrist. As my career evolved, I took a job at our local state hospital, running a ward. I offered to be an attending psychiatrist on one of the geriatric wards, which felt right. My mother told me, "I hope you can do as good a job as that young doctor did for Tressy."

I tried. But, the state hospital closed down—a victim of budget cuts. I know that state hospitals don't have the best reputation, and I know that sometimes that reputation is deserved and sometimes it is not. What I really know, though, is that sometimes people go around and around on the tracks and need a place to get unstuck.

The state hospital where I worked occupied the same hill for over 150 years, and during that time, it had expanded and then contracted. Still, the state hospital represented most of the psychiatric beds in the area it served. Community mental health leaders and the state officials met and worked out a five-year plan for the institution, agreeing to further limit beds and admissions and expand outpatient care. Two years into the five-year plan, the state closed the facility. The state or the state's budget couldn't wait. The state announced that it would close the doors of the hospital and then, after the fact, had hearings. One mother stood up and said she had two children. One had an earache, she said, and she was able to get a doctor's appointment that night. One had schizophrenia, but she had to wait three months for him to be seen.

This was the second inpatient unit that closed while I was working in it, and the experience was similar. When the money runs out, or if the institution has budget problems, no one says, "Thanks for your work, but we can't afford this any more." Instead, your work is viewed as being outmoded, wrong, or even inhumane. It's easier to say, "We're moving forward," rather than "We decided to shut this down to save money" or "Look, cardiology makes more money" or "The state's bridges and roads need attention." Instead, the argument is made somehow that providing fewer services is better, more modern, even more humane and that those who would disagree are wrong or unethical or both. Having been through this before in another setting, I wasn't surprised, but I was disappointed. In one meeting, an administrator asked people to identify themselves—who was a mental health employee, who had been a psychiatric patient, and who was a family member of a patient. I raised my hand for all three, although I think we were supposed to pick sides.

So the state hospital closed. That meant that most of the psychiatric beds in the area were lost along with it. The wait to get someone into remaining long-term care hospital beds stretched from days into months. The pressure on community hospital inpatient units increased. They were fuller, lost more money, and had to close more beds. The outpatient clinics continued to have their three-month wait for care, and emergency rooms became de facto holding units until an inpatient bed opened. No acute day hospital or partial-hospitalization psychiatry program existed in the county. When the closure of the state hospital was announced, the number of people on the waiting list for supportive housing equaled the number in supportive housing.

Although I understand that there are no state cardiac hospitals and no state orthopedic hospitals, there have been state psychiatric hospitals for over a century and a half. Driven in part by women concerned about social issues, the states acknowledged in the 19th century that people were suffering from psychiatric illnesses and substance abuse and reached out to help. This movement sought to provide humane care for those with mental illnesses and remove them from the almshouses and prisons. Now we have "advanced" to sending people to homeless shelters and prisons. As was pointed out to me, the cost of a prison bed is a lot cheaper than a state hospital bed.

Over the past century and a half, these institutions have grown and then withered, and as the bureaucracy has grown, not all the turns the mental health treatment movement has taken are good. Certainly there have been abuses of power and treatment. Patients' rights have not always been respected. But back in the day, state hospitals saved my grandmother's life. On the admissions units where I worked, families would often say, "They just needed some time to get right," feeling that repeated three- or four-day hospital stays were simply not enough. Many could be discharged from long-term units if intensive, inclusive treatment existed in the community. Those with severe mental illness and substance abuse and those with brain injury and a history of violence are often more ill than others and frequently need even more intensive care.

So, what should be done? I hope that I am not arrogant enough to suggest that I know the answer. But, the mental health movement over the centuries has sometimes been led by charismatic people who "knew" what was best. Ideas have ranged from housing people in bucolic surroundings or asylums, to lying on a couch to clear their head, to ECT, and to "atypical" medications. Although each treatment probably advanced the field, none was (or is) the answer. And a wide array of other treatments, including malaria injections, lobotomies, and primal screams, were either harmful or silly. Closing hospitals and psychiatry beds is cheaper, but we have to question whether doing so is better or more humane for people with serious mental illness.

What I do know is what I saw when I was eight years old: with treatment, people do better.

With help, many people can go back to their old selves or establish new selves. But all treatment costs money. Discussing how to spend that money is essential, but in doing so, we must not take sides. I have seen the enemy, and it is not us—the caregivers. When people are dragged down by illness, help must be available and sometimes is dramatically useful. But people can't always get there by themselves. When you get stuck, sometimes you need some more help, and sometimes it takes more than one person to get you out of that last car on the train.

The content of this article does not necessarily reflect the views of the U.S. Department of Veterans Affairs.

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