The Death of the Asylum: A Critical Study of State Hospital Management, Services, and Care

To review a book written a quarter of a century ago is no easy task. It is easy to find fault when the outcome is known, if only because hindsight confers the kind of wisdom that was not available to the book's author at the time. A retrospective review, therefore, requires a strategy that evaluates the work within the context of its own time.

The Death of the Asylum: A Critical Study of State Hospital Management, Services, and Care was written at a time when deinstitutionalization of persons with severe and persistent mental illnesses had failed to live up to its promise. The passage of the Community Mental Health Centers Act in 1963 had presumably begun a process that would result in the closure of state mental hospitals and the transfer of care to the community. A decade and a half later it had become clear that the legislation had not achieved its purposes. Not only had the creation of community mental health centers fallen far short of the projected 2,000 centers, but the centers that had come into existence served quite different populations. To be sure, the resident populations of state hospitals had fallen dramatically, but a good part of the decline had occurred after the passage of Medicaid in 1965 and the transfer of older persons to chronic care nursing facilities. Many people who were discharged from institutions faced great difficulties in communities that were ill prepared to provide necessary care and treatment. Nor had state hospitals begun to disappear, even though there was a slight reduction in their number. The creation of Jimmy Carter's Presidential Commission on Mental Health in 1977 was but one indication of the inability to implement an effective community policy.

At the time that Talbott published this book he was already known as a shrewd critic of mental health policy. He was involved with Carter's Presidential Commission and arranged a conference dealing with persons with chronic mental disorders that both influenced the Commission's final report and led to a published volume. The Death of the Asylum was a book that chronicled the failures of state hospitals as well as the policy of deinstitutionalization. Yet in calling attention to these failures, Talbott emphasized the central importance of individuals with serious and persistent mental disorders. By the time this book appeared, this group no longer occupied the center of mental health policy. The emphasis on individuals with psychological and addiction problems had created an entirely new clientele that competed for resources, to the detriment of those with chronic disorders. Yet the needs of the latter, as Talbott emphasized, were far greater: "They are people who have impaired social functioning, psychological disability, and residual symptoms. They often have no home, no family, and no friends to whom to return. There is all too often no viable ecological system or social structure awaiting their return. All the above makes it imperative that we use a model of chronic illness in thinking about this population, and that the goal after resolution of the acute episode must be care not cure and habilitation before rehabilitation."

In detailing the shortcomings and failures of the mental health system in 1978, Talbott did not offer any simple solutions. He recognized the need for advocacy groups, for an integrated system of care and treatment to overcome the fragmentation of services, for greater responsibility and accountability, and for adequate resources. To dismantle state hospitals would not provide a solution, if only because programs and services for individuals with severe and persistent disorders would still be required, including, as Talbott shrewdly observed, "asylumlike settings": "Whether this needed system will arise phoenix-like out of the ashes of the asylum or replace it before its death is problematic."

It is, of course, possible to be critical of the analysis presented in The Death of the Asylum. From a historical point of view, mental hospitals performed important functions at a time when alternatives to institutionalization were lacking. They provided food, clothing, and shelter for a vulnerable population that was severely disabled. Moreover, between 1890 and 1960 they assumed the role of old age homes for individuals suffering from mental disabilities related to advancing age. The assignment of responsibility for caring for aged persons was not voluntary; it was thrust upon the hospitals by governmental policies that had the inadvertent result of magnifying their custodial character. At the same time, as Morton Kramer pointed out in a significant study of a Pennsylvania state hospital, many patients benefited after only brief stays. To offer blanket condemnations tends to ignore the fact that mental hospitals provided important services that would have otherwise been unavailable. Nor were institutions monolithic. This is in not to imply that hospitals provided high-quality care and treatment, for such was assuredly not the case. Yet an emphasis on the hospitals' deficiencies can often obscure their important functions.

What is most significant about this book is that it emphasized the shortcomings of the mental health system and offered realistic alternatives. Although there have been some positive developments since 1978, the plight of individuals with severe and persistent mental illnesses remains as pressing as ever. Indeed, the recent report of President Bush's New Freedom Commission in many ways simply reiterates much of Talbott's analysis. To so note is to recognize Talbott's significant contributions to the field.

Dr. Grob is affiliated with the Institute for Health in New Brunswick, New Jersey.