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October 2011

by Gaije Kushner

There's no great time or place in which to be crazy. Wherever, whenever, it's going to be messy, complicated, and expensive. With so many worst case scenarios available, it's impossible to decide which one is the absolute, real, worst. You could be locked away in an attic, subjected to torturous rites of exorcism, handed over to inquisitors, or burnt or stoned to death as a witch.

An unlikely high point in the history of mental health care was the 1852 opening of the Alabama State Hospital for the Insane, known today as Bryce Hospital. In everything from architectural design to treatment of residents, Bryce was part of a radically new approach to caring for the mentally ill. Rather than seeing them as monsters, whose confinement public safety necessitated, the Moral Treatment movement aimed to offer them the dignity and respect due their humanity.

Moral Architecture, which saw therapeutic potential in the buildings themselves, guided their design. Thomas Story Kirkbride, originator of the popular Kirkbride plan, called it, "a special apparatus for the care of lunacy [whose grounds] should be highly improved and tastefully ornamented." Connected buildings were staggered, allowing each access to sunlight and fresh air. The new plan was unique in its consideration of patients' comfort and privacy.

Once the buildings were inhabited, superintendent Peter Bryce carried those values into its management. Physical restraints were abandoned. Sensitivity and competence were expected of staff. Patients had work to do: farming, sewing, maintenance, or crafts, according to their abilities and inclinations. For a time, there was even a newspaper—The Meteor—written, edited, and published by residents. Holiday celebrations were organized, visits and gifts from home encouraged. Bryce was nationally renowned as a model of modernity.

It didn't stay that way for long. Growing up in 1980s Alabama, the word Bryce alone sufficed to provoke a late-night, sleepover thrill of fear. Were we scared of the place, or its inmates? Some combination of the two, most likely. Bedraggled women, dressed in rags, howling, shackled to dungeon walls, fed only gruel, whatever that is exactly. Scary to be them, scary to be near them.

Things didn't get quite that bad, but they might have, sooner or later. In 1970, a class action lawsuit was brought on behalf of Bryce's patients. Overpopulated and understaffed, the hospital had deteriorated into the kind of warehouse institution its founders loathed. A year later, the plaintiff class grew to include residents of Alabama's other public mental hospitals. Court supervision lasted over 30 years, until 2003.

The case, Wyatt v. Stickney, carries the dubious distinction of having formed the basis for national minimum standards of care for the mentally ill: humane environments, qualified and sufficient staff, individual treatment, and the least restrictive environment feasible. Hospital administrators could have saved everyone a lot of time and trouble, just by sticking with their founding principles.
The principle of the least restrictive environment, and the development of more effective, better tolerated medications, led to deinstitutionalization of the mentally ill. Along with it came ideas like consumer-driven care and a new recovery model. Community-based care is consistently more effective, and less expensive, than institutional care. For instance, a year of residency at Bryce currently costs $132,000. A year of community care, $60,000. The problem, in Alabama and elsewhere, has been the initial investment required to construct a system of community care. The savings don't start until the residents have been moved. As soon as they've been moved, they need care, which can't be funded until after they've moved. Maddening.

Last year, the Alabama Department of Mental Health sold Bryce to the University of Alabama for $87 million, $77 million of which will actually go to the ADMH. Most residents will go into community-based care, we're told. A reasonable person might expect profits from the sale to fund the care they'll need. But that's not how we do things in Alabama. That money will go towards the estimated $82 million it will cost to replace Bryce with a smaller facility. So where's the money for all that consumer-driven, community-based care going to come from? No one seems quite sure.

It's not as if Alabama has a reasonably effective community-based system already in place, ready and waiting for more consumers. Oh, no. We have don't have enough beds available in group homes, or for acute care. Best of all, 42% of Alabamans live in federally-designated mental health professional shortage areas. Who knew such a thing existed? We don't even have enough psychiatrists, who are kind of important to the practice of mental health care. The ADMH has responded by funding a few new psychiatric residencies and easing some requirements for state licensure. Maybe that will do it, inspire doctors to live in Arab, or Ozark, instead of Atlanta, or Boston.

In case that doesn't work, there's telepsychiatry—treatment via video chat, more or less. And offering primary care physicians additional training to better enable them to diagnose and treat serious mental illness on their own. There are so many reasons why these are terrible ideas, it would require another article to list them. The whole thing demonstrates an utter disregard for the quality of care available to mentally ill Alabamans.

Both state and federal funding for mental health care will be cut next year, by an estimated $28 million. ADMH spokesman John Ziegler says, "It is so profound that it would impact our entire system." With 2500 people currently wait-listed, how much worse can the system get? Not as bad as the burning alive, no. More like being locked away in the attic.


Bryce residents named the newspaper they produced from 1872 until 1883 or so The Meteor because, "Meteors are always a surprise. So doubtless will be our little sheet. They appear at irregular intervals. So will it. Their career, though short, is brilliant, and we intend that our paper, if it do not corruscate with wit, shall glow with a kindly and generous sentiment for all mankind, whatever be their nationality, political principles, or religious creed."

The papers are full of the unlikeliest things. Accounts of holiday parties, an antipathy towards Darwinism, a timely and abiding interest in spiritualism, practical jokes played on one another. One woman, expecting a gift recognizing her as "the most industrious member of the sewing societies" instead received a toy watch, and was told, "Lady, you have, through your industry by day and by night, with your hands, and doubtless too, with your tongue, demonstrated your right to a high place amongst industrious lunatics."

Residents seem to have felt a kind of friendly rivalry with their nearest neighbor, the nascent University, taking note of its academic achievements, and explaining, "The inmates of the university come to acquire ideas. We to get rid of them. They receive encomiums for proficiency in military tactics. The slightest proclivities in that direction, at our house, insure rebuke. If a student is insubordinate, or irregular in his deportment, he is sent home. The more obstreperous our behavior, the closer we are held."

I'm left wondering just how productive I'd have to be, to earn myself a high place amongst industrious lunatics these days. Odds are against it, but you never know.

 

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