Mental Health Institutions- A Recent History

(EDITOR'S NOTE: Yesterday the News introduced a controversy over the level of treatment provided at Ypsilanti State Hospital that has been precipitated by a lawsuit aimed at preventing the closing of its Ward C1-3. Today we begin a series examining the adequacy.of treatment for patients in the state's mental hospitals now and in the future.) First Of A Series Large institutions like Ypsilanti Slate Hospital were once the only option available for the care of victims of mental illness whose families could not or would not handle them at home. But the shortcomings of such institutions have long been recognized. Many studies have shown that for a large number of patients. institutions do not provide an environment in which they can get well (if the patient's condition tnakes such a prognosis appropriate) or fully develop their potential whatever its limits are. "In the old days, they thought the best (and cheapest) way to care for patientsj in mental institutions was to build foun walls around them," says Ypsilanti State Hospital Superintendent Dr. Vernon A. Stehman. Back in the fifties, he says, a women's psychiatrie unit in YSH vvhich nou has a I stated capacity of 50 beds (translate 50 I persons), had 115 yvomen in H. Another staff person who was there in those not-so-good old days recalls that there were so many patients, in f act, that lor a time"; they were bedded down on L oak benehes along the walls oí a riay I room. And beföre he carne. Dr. Slehman I says. the place was "bedlam" in the I original sense of the word. "They I screamed; s'onïe tore their clothos off as last as you could put them back on." What changed that? Pari of the answer is drugs. Drugs which bio-chemically alter the functions of the brain. Drugs which quiet a pa tient's anxieties "Drugs are the most effective treatmenl mode we have." Dr. Stehman stales. "The impact when they were inI iroduced in the fifties was phenomenal. Drugs allowed us to throw away the I slrait jackets; they quieted down the paI lients in the most wildly di.sturbed I wards. They got people out who hadn't I been outside lor a long time." ■ The psycho-lropic drugs, along with I some other new modes of treatment. M have, in f act, made il possible for_manv i institutiohal patients to be returned home or placed in smaller, communitybased facilities, where they do much better. While the effective implementation of community placement programs is itself plufiuod with problems and controversy, théir potential superiority as a means of j treatment lor many of the mentally ill j has been reeognized in this state (and elsewhere. too) in legislation, in budgetink and in mental health department. planning. The reduction of patiënt populations in Michigan's mental health hospitals (Ypsilanti State is one of 12 in the state system - and close to the largest in number of patients and in budgeting, according to Acting Director of the Michigan Department of Mental Health Dr. Donald C. Smith), is therefore proceeding at a rapid rate. Still, few but the most radical critics of earlier modes of treatment suggest that there is no place at all for institutions in a comprehensive program for the care and treatment of the mentally ill. It is difficult to generalize about the population of state mental hospitals on the basis of specific illnesses. Some patients have problems considered to be jprimarily psychiatrie in nature. Some ïave organic problems of genetic orgin. ome are brain damaged a result of r nesses of physical injuriesM'hat occurred , at some time later in life. Some are erly people suffering from what is , ally called senility. Some are even chronic alcoholics or drug dependents. The new state mental health code, most of the provisions of which go into effect on August 6, defines a candidate for institutional care more simply as a person who is mentally ill, and who as a result of that mental illness: "Can reasonably be expected within the near future to intentionally or unintentionally seriously physically injure himself or another person, and who has engagecT in an act or acts or made significant threats that are substantially supportiye of the expectation" -"is unable to attend to those of his básic physical heeds such as food, clothing. or shelter that must be attended to in order for him to avoid serious harm in the near future, and who has demonstrated that inability by failing to attend to those basic physical needs." And while it is the new mental health code that implements the shift in the state's emphasis from institutional to community based treatment programs, the code also "demands," according to Dr. Smith, "a more aggressive approach" to the treatment of those for whom ■ tional care is still deemed necessary. What is an "adequate" level of I ment? Stories in yesterday's News' described I one ward at YSH where treatment was I feit - by staff, by patients, by a legal I aid attorney and by Dr. Stehman as well I - to at least approach some such I ard. Bul some of those parties eontend that that ward - Education and Training Unit Cl-3 - soon to be closed as a result of staff reductions, was unique in the level of treatment it provided. Let Dr. Stehman guide you on a tour ol the women's psychiatrie unit he spoke of above. Unlock the door. Relock it after I you've entered. Try to ignore the stares and go on inside. Some of the women have been on this ward since the day the institution opened over 40 years ago. Others have been here much less time. H But for all of them, there is the ending of the private life. The kek of any time when they can be alone, in the sense of being physically apart from others. Their privacy comes from excluding others by staring out of the barred windows onto the wards, other corridors other patients. ■ And by retreating into themselves. Can anyone get "better" in this kind of environment? Dr. Stehman admits it's ■ difficult - that it harms a person's sensitivity to be constantly looked at, infringed upon by others. Look around you in the day room. ' It appears to be almost as long and as wide as a football field. No partitioñs break up this great expanse of space. In remodeled wards, like Cl-3, these most unspacious of large rooms have been broken up into smaller areas. But the ■ day rooms of the old wards linger on, imposing their cavernous existences on their ward's patients. What is a day room anyway? U's a room in whieh a ward's patients spend their days. What do patients do in a day room? They sit mostly. In the old days they M were, in fact, seated out in the day room, to spend the entire day just sitting there. Now, they're more free to move around. Bul many patients still sit. Some staring blankly and not seeing, some so embroiled in themselves that they seem not to notice what's going on. Some talking to So go the lives of many who will never I be released because they are too ill to be I placed in community living facilities. I Lives led behind locked doors and barred I Windows. Lives on corridors. Lives I where in some of thè old, remodeled ■ wards, there are no toilet seats or partiW tion doors for privacy between stalls. I Where nothing is private. That former "bedlam" whose patients I now lead more placid lives. Adequate? No one claims that this is the case. Though serious efforts are being made lo reduce drug usage (for one thing because patients can become saturated ' with a drug so that it no longer has the I desirable effect). Dr. Stehman I j edges the tendency to want to overuse I I them. "For those staff persons who I I Iht what the hospital was like 25 years I I ago; there is a reluctance to discontinue I I medications because they remember I I what it was like here once. They know I I what can happen." What does it take to turn the potential I I prpmised by the psycho-tropic drugs I I from another form of strait jacket into I I adequate '"treatment"? One obvious answer is adequate staff. I But the staff at Ypsi State Hospital is I I not growing. On the contrary it is being I I reduced. As part of a state level management I I plan developed by the Department of I [Mental Health to implement the new fmental health code, a staff-to-patient ratio of one-to-one has been established In ihe years when the women's [psychiatrie unit had 115 patients, YSH had a total patiënt population of approximately 4,100. Now its total population lies cl(i.se to l 000. Since Dr. Stehman became superintendent at YSH in 1971, over 300 patients have been leaving the institution vearly, most of them to live in community placement facilities, and further I ductions in patiënt load are projected. I And that one-to-one staff-patient ratio I is being enforced in such a way as to I duce the number of staff left to care for I those too ill to leave the hospital It is the need to comply with that ratio I (YMi was 30 staff over on July 1) that I d Dr. Stehman to order the closirm „f I the "adequate" care training unit vüird. I Cl-3. It does not seem unreasonable to 1 peet some reductions in the number ol'fl staff in institutions where patiënt loadsl I have dropped substantially. And a I lj)-one staff-patient ratio does not sound I I 1 bad on the surface. But will it provide an "aggressive" - or even adequate - level of treatment tor institutionalized patients? That question will be explored in Part Two of this series on Page 15 of Tuesday's News.