State Hospitals: Problems and Potentials

In State Hospitals: Problems and Potentials, John Talbott, editor of the book and contributor of three chapters (two with a coauthor), provides the opening exposition, "The Problems and Potential Roles of the State Mental Hospital." Talbott indicates that the problems encountered by state mental hospitals can be grouped into 11 areas: physical plant, patients, staff, treatment programs, service systems, state departments of mental health, other departments or agencies in state government, state legislatures, outside agencies or forces, lack of a constituency, and lack of adequate funding. He suggests needed changes in societal and professional attitudes, funding priorities and mechanisms, administrative structures and procedures, and program planning and implementation.

According to Talbott, each state hospital's future role in this morass comes from among four options: closure, maintenance of the status quo, radical reform, or alteration of functions. Talbott points out that at the end of the 1970s hospital closures were stalled because of the backlash against deinstitutionalization. It seemed increasingly unlikely that state hospitals would be retained in their current form. Radical reform appeared to be too idealistic given the current disasters in the state hospital system. Thus alteration of functions seemed the most propitious direction to take. With the state system "tottering on the brink of disaster—financially and clinically," something had to happen.

Having set the stage, Talbott lets the experts speak for themselves—a cohort of 14 men representing the public mental health system, the Veterans Administration, and academia. (The absence of women seems to reflect the time; the male contributors to this volume had each accumulated experiences for decades before the book was written.) Emulating Talbott, in this review I let these guys speak for themselves. Their messages are both precious and prescient.

Frank James: "State government has demonstrated for 200 years that its priorities have not included the mentally ill; that it is not responsive to the needs of such an apolitical group, and that it is not receptive to the kind of clinical leadership, untethered by political ties, that is needed to accomplish the job."

Lawrence Kolb: "The delusion must be dispelled that modern biopsychosocial therapies have done away with chronicity of socially impairing behavior in many who have and will suffer psychoses."

Henry Brill: "We were misled when we hoped that modern methods would reduce long-term disability to the vanishing point; what remains to be determined is what proportion of persons may have a better quality of life in a state hospital type accommodation and what proportion will do better in some type of community setting."

Stuart Keill: "Without good leadership and localized accountability it is very difficult to have both a quality and public mental health system, at least as our departments of mental health are now constituted."

Anthony Arce: "The capacity of state mental health programs to change in response to the articulated needs of the society around them may be the single most important determinant of their growth and viability."

Robert deVito: "While administrative and programmatic reasons should form the basis of any plan for facility change, economic and political factors become the dominant forces that determine whether or not a plan will 'take.'"

James Barter: "No one advocated for a return to the traditional state hospital, or to custodial levels of care for the mentally ill. The future direction of the state hospital must be toward finding new roles and responsibilities complementary to community mental health programs."

Irwin Greenberg: "If it is recognized that even those who are seriously ill are nevertheless equal in their right to care, and that such care may not be wholly "economical," then there may be a viable, humane state hospital system, or if not, a place within the community for the severely and chronically disabled."

Israel Zwerling: "The most serious flaw…is the failure of academia to prepare mental health workers for careers in the public mental health sector and to promote research relevant to that sector."

Robert Daly: "The superintendent, in order to administer the modern state hospital, must be technically competent in executive functions and have the personal characteristics of a facilitator."

Francis Tyce: "To maintain highly trained professionals in administrative work only is to waste their expertise and leads to program design without continuing experience, and communication by memoranda—a time-consuming, self deceiving, relatively inaccurate method of communication." (What Tyce says about memoranda could perhaps be said of e-mail today.)

Richard Filer and Jack Ewalt: "The desire for security sometimes becomes so intense that it obscures deeper and more significant values—individuality and personal dignity. In a sincere effort to aid people in need, societies for years have established various forms of institutions, and sometimes the desire to provide security has become the ultimate goal."

Lest the reader feel that so little has changed in 25 years that Talbott could just as easily have edited this text in 2003, and lest this perception leave the reader feeling down and out, I end this review with a remark from the expert whom Talbott chose to close State Hospitals, Lee Macht, a former mental health commissioner, Harvard professor, and department chair at the Cambridge City Hospital. Macht's death at an early age still reverberates in Boston. He challenges us still: "If we became enmeshed in a web of pessimism, hopelessness, or apathy, state services will deteriorate further. Rather, at various levels of professional activities including programs, professional societies, and government we must look for opportunities and capitalize on them. Rather than throw up our hands in despair we should become leading advocates for high-quality patient care."

Dr. Geller is professor of psychiatry and director of public-sector psychiatry at the University of Massachusetts Medical School in Worcester.