somewhere else…

Posted on Saturday 28 December 2013

The article about the homeless mentally ill in Raleigh NC [“just a mental health patient living on the street”…] is in part related to the closing of the Dorthea Dix hospital last year. This is a bit of history about Dorthea – the irony and parallels to today won’t be lost on anyone:
Dorthea Dix [1802 – 1887]Wikipedia

She was born in the town of Hampden, Maine, and grew up first in Worcester, Massachusetts, and then in her wealthy grandmother’s home in Boston. She fled there at the age of twelve, to get away from her alcoholic family and abusive father. She was the first child of three born to Joseph Dix and Mary Bigelow, and had deep ancestral roots in Massachusetts Bay Colony. Her father was an itinerant worker.  About 1821 she opened a school in Boston, which was patronized by the well-to-do families. Soon afterwards she also began teaching poor and neglected children at home. But her health broke down, and from 1824 to 1830 she was chiefly occupied with the writing of books of devotion and stories for children. Her Conversations on Common Things [1824] had reached its sixtieth edition by 1869. In 1831 she established in Boston a model school for girls, and conducted this successfully until 1836, when her health again failed. In hopes of a cure, in 1836 she traveled to England, where she had the good fortune to meet the Rathbone family, who invited her to spend a year as their guest at Greenbank, their ancestral mansion in Liverpool. The Rathbones were Quakers and prominent social reformers, and at Greenbank, Dix met men and women who believed that government should play a direct, active role in social welfare. She was also exposed to the British lunacy reform movement, whose methods involved detailed investigations of madhouses and asylums, the results of which were published in reports to the House of Commons.

After she returned to America, in 1840-41, Dix conducted a statewide investigation of how her home state of Massachusetts cared for the insane poor. In most cases, towns contracted with local individuals to care for people with mental disorders who could not care for themselves, and who lacked family and friends to provide for them. Unregulated and underfunded, this system produced widespread abuse. After her survey, Dix published the results in a fiery report, a Memorial, to the state legislature. "I proceed, Gentlemen, briefly to call your attention to the present state of Insane Persons confined within this Commonwealth, in cages, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience." The outcome of her lobbying was a bill to expand the state’s mental hospital in Worcester. Henceforth, Dix traveled from New Hampshire to Louisiana, documenting the condition of pauper lunatics, publishing memorials to state legislatures, and devoting enormous personal energy to working with committees to draft the enabling legislation and appropriations bills needed to build asylums. In 1846, Dix travelled to Illinois to study mental illness. While there, she fell ill and spent the winter in Springfield recovering. As she recovered, she worked on research, and submitted a report to the January 1847 legislative session, which adopted legislation to establish Illinois’ first state mental hospital.

Dorthea Dix Hospital - Raleigh NC 

In 1848, Dorothea Dix visited North Carolina and called for reform in the care of mentally ill patients. In 1849, when the North Carolina State Medical Society was formed, the construction of an institution in the capital, Raleigh, for the care of mentally ill patients was authorized. The hospital, named in honor of Dorothea Dix, opened in 1856. She was instrumental in the founding of the first public mental hospital in Pennsylvania, the Harrisburg State Hospital, and later in establishing its library and reading room in 1853. The culmination of her work was the Bill for the Benefit of the Indigent Insane, legislation to set aside 12,225,000 acres of Federal land, 10,000,000 acres for the benefit of the insane and the remainder for the "blind, deaf, and dumb", with proceeds from its sale distributed to the states to build and maintain asylums. Dix’s land bill passed both houses of Congress, but in 1854 President Franklin Pierce vetoed it, arguing that the federal government should not commit itself to social welfare, which was properly the responsibility of the states…
A year ago, I had a shot at talking about this history [on history…]. One’s view of things is heavily colored by the place where you came into the historical stream. I came along when there were remnants of a mental health system though in obvious decline, and like many people my age, I trained in the State Hospital system. This is how the Unit where I spent 6 months and the library where I spent my spare hours look today:


The big institution, Central State Hospital in Milledgeville Georgia, finally closed for good in 2010 [at age 166 years]. Some pictures from then and now:

I said I came in at a time when things were in obvious decline, but in retrospect, in 1974 I made it just under the wire. The system at that time was oriented towards short term hospitalization and community liason. I was lucky to be on Unit where that system worked. We had enough time to manage the acute problems that lead to hospitalization and could insure solid placement in communities with adequate resources and follow-up. It was challenging rewarding work. Not many years later, my office as Director of Residency training was on the campus. I visited that same Unit and saw that it had been essentially destroyed by the excessive admission rate from the closing of too many State facilities. It had become a warehouse. I had to pull my residents off of that Unit where I had learned so much. They were being misused and only learning to be bitter. I involuntarily teared up that day. It seemed so utterly pointless.

We used to be called Alienists, reflecting an outside view of the psychotic patients. But after an early period of adjustment, one doesn’t feel like that. There’s a way that these patients think and  approach living that’s difficult for them and others, but it’s just the way things are. Once you learn it, it’s no longer alien, and there’s a great deal you can do for them. There are some wonderful recoveries, some tragedy, and a lot in between. The idea of Asylum is that it’s the somewhere else [“just a mental health patient living on the street”…] they need to come back to when the world at large becomes impossible. That’s what they’re looking for in those ERs in Raleigh. It doesn’t have to be a hospital. But it does need to be. If you work in a functional version, you know that medication is helpful, but hardly the answer, particularly long term. In my experience, over-medication is a direct result of not having appropriate resources for effective care and Asylum.

I try to stay out of the endless debates about what "ought to be done" – usually made by people who haven’t lived among these patients. I skirt accusations that "all you psychiatrists want to do is medicate people," in part because that’s true of some of today’s psychiatrists, but in part because that’s sometimes all those psychiatrists can do in the current circumstances. But I do have something to say. I retired to a very small place and I work in a charity clinic. There’s also a contract mental health center with a "telepsychiatrist." The courts and law enforcement people know every chronic mental patient in the county and have created something called "mental health court" – essentially a magistrate and some case workers who keep tabs on the patients. It’s a little like probation but more like community social work. I’m not even completely sure how it all works – but it does work. I’m in awe. And no one lives on "the street." When a community is forced to deal with an issue, it does. It creates a system that has Asylum and sanctuary built into whatever spaces it can find. There are many kinds of somewhere else

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