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Psychiatric hospital

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This article is about modern psychiatric hospitals. For historical lunatic asylums, see Lunatic asylum.
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Danvers State Hospital, Danvers, Massachusetts, Kirkbride Complex, c. 1893
Springfield State Hospital, Sykesville, Maryland, Cottage Plan, c. 1896
McLean Hospital's administration building in Belmont, Massachusetts; the hospital treated several notable New England residents, including Massachusetts governor Nathaniel P. Banks, musician James Taylor, and poet Anne Sexton
The various restraints and apparatuses pictured were utilized within Hanwell Asylum in London to restrain patients.

A psychiatric hospital, also known as a mental health hospital, a behavioral health hospital, or an asylum is a specialized medical facility that focuses on the treatment of severe mental disorders. These institutions cater to patients with conditions such as schizophrenia, bipolar disorder, major depressive disorder, and eating disorders, among others.

Overview

Psychiatric hospitals vary considerably in size and classification. Some specialize in short-term or outpatient therapy for low-risk patients, while others provide long-term care for individuals requiring routine assistance or a controlled environment due to their psychiatric condition. Patients may choose voluntary commitment, but those deemed to pose a significant danger to themselves or others may be subject to involuntary commitment and treatment.[1][2]

In general hospitals, psychiatric wards or units serve a similar purpose. Modern psychiatric hospitals have evolved from the older concept of lunatic asylums, shifting focus from mere containment and restraint to evidence-based treatments that aim to help patients function in society.[3][4] Drug administration, as well as structured and one-to-one therapy (such as occupational therapy and psychotherapy) play a role in trajectories. They are the focus of most studies on forms of treatment that exist in psychiatric wards. However, because psychiatric wards are social living spaces, inpatient relationships in psychiatric wards also play a role in survival and recovery trajectories.[5]

With successive waves of reform, and the introduction of effective evidence-based treatments, most modern psychiatric hospitals emphasize treatment, usually including a combination of psychiatric medications and psychotherapy, that assist patients in functioning in the outside world. Many countries have prohibited the use of physical restraints on patients, which includes tying psychiatric patients to their beds for days or even months at a time,[6][7] though this practice still is periodically employed in the United States, India, Japan, and other countries.[8][9]

History

Main article: Lunatic asylum
York Retreat, built in the late 18th century by William Tuke, a pioneer in moral treatment of the mentally ill

Modern psychiatric hospitals evolved from, and eventually replaced, the older lunatic asylum. Their development also entails the rise of organized institutional psychiatry. Hospitals known as bimaristans were built in the Middle East in the early ninth century; the first was built in Baghdad under the leadership of Harun al-Rashid. While not devoted solely to patients with psychiatric disorders, early psychiatric hospitals often contained wards for patients exhibiting mania or other psychological distress.[10][new archival link needed]

Because of cultural taboos against refusing to care for one's family members, mentally ill patients would be surrendered to a bimaristan only if the patient demonstrated violence, incurable chronic illness, or some other extremely debilitating ailment.[11] Psychological wards were typically enclosed by iron bars owing to the aggression of some of the patients.[12]

In Western Europe, the first idea and set up for a proper mental hospital entered through Spain. A member of the Mercedarian Order named Juan Gilaberto Jofré, who was a Mercedarian friar, traveled frequently to Islamic countries and observed several institutions that confined the insane. He proposed the founding of an institution exclusive for "sick people who had to be treated by doctors", something very modern for the time. The foundation was carried out in 1409 thanks to several wealthy men from Valencia who contributed funds for its completion. It was considered the first institution in the world at that time specialized in the treatment of mental illnesses. The Hospital de los Inocentes in Valencia was founded, likely based upon similar foundations which Jofré had witnessed in North Africa or Muslim Granada. After the foundation of this hospital followed various other facilities which were dispersed throughout the Spanish Kingdom. These facilities which continued to spread were modeled loosely on their Arab predecessors and what they had built. Construction continued and by the middle of the sixteenth century all three cities of Seville, Toledo, and Valladolid had their own hospital purely for the care of the mentally incapacitated. Though these hospitals were constructed, they still focused purely on the care of those who were most desperate for care. Those admitted typically were seen to be a danger to themselves or others within society.[13]

Later on, physicians, including Philippe Pinel at Bicêtre Hospital in France and William Tuke at York Retreat in England, began to advocate for the viewing of mental illness as a disorder that required compassionate treatment that would aid in the rehabilitation of the victim. In the Western world, the arrival of institutionalisation as a solution to the problem of madness was very much an advent of the nineteenth century. The first public mental asylums were established in Britain; the passing of the County Asylums Act 1808 empowered magistrates to build rate-supported asylums in every county to house the many 'pauper lunatics'. Nine counties first applied, the first public asylum opening in 1812 in Nottinghamshire. In 1828, the newly appointed Commissioners in Lunacy were empowered to license and supervise private asylums. The Lunacy Act 1845 made the construction of asylums in every county compulsory with regular inspections on behalf of the Home Secretary, and required asylums to have written regulations and a resident physician.[14] The Lunacy Act of 1845 also forced counties to provide these asylums as publicly funded establishments. By 1914, the construction of these asylums came to an abrupt stop with the beginning of World War I. At this point in time each English county had at least one or more publicly funded Pauper Asylum. [15]

At the beginning of the 19th century there were a few thousand people housed in a variety of disparate institutions throughout England, but by 1900 that figure had grown to about 100,000. This growth coincided with the growth of alienism, later known as psychiatry, as a medical specialism.[16] The treatment of inmates in early lunatic asylums was sometimes very brutal and focused on containment and restraint.[3][4] Between the years of 1979 and 1982 about 30 patients within psychiatric hospitals died within the state of New York due to being either secluded or restrained. [17]

In the late 19th and early 20th centuries, psychiatric institutions ceased using terms such as "madness", "lunacy" or "insanity", which assumed a unitary psychosis, and began instead splitting into numerous mental diseases, including catatonia, melancholia, and dementia praecox, which is now known as schizophrenia.[18]

In 1961, sociologist Erving Goffman described a theory[19][20] of the "total institution" and the process by which it takes efforts to maintain predictable and regular behavior on the part of both "guard" and "captor", suggesting that many of the features of such institutions serve the ritual function of ensuring that both classes of people know their function and social role, in other words of "institutionalizing" them. Asylums is a key text in the development of deinstitutionalization.[21]

With successive waves of reform[when?] and the introduction of effective evidence-based treatments, modern psychiatric hospitals provide a primary emphasis on treatment; and further, they attempt—where possible—to help patients control their own lives in the outside world with the use of a combination of psychiatric drugs and psychotherapy.[22][full citation needed] These treatments can be involuntary. Involuntary treatments are among the many psychiatric practices which are questioned by the mental patient liberation movement.[23] The Mental Patient Liberation Movement developed between 1950 and 1960. The movement was driven by the effort to gain more rights for mental patients and ex-patients who felt their constitutional rights had been violated. These violations included unjust incarceration, drugging until incapacitation, and the removal of normal forms of communication such as mail or telephone. The movement worked towards changing the handling of deviant behavior to treat people in a more humaine manner and correcting this behavior through treatment rather than punishment. Overall, the primary objective of the movement was reforming institutional commitment procedures. [23]

In America history in the 1980s after the "12,225,000 Acre Bill"[clarification needed] it was emphasized that care would be given in asylums instead of housing the individuals in jails, poorhouses, or having them live on the streets.[clarification needed] Due to the decrease over the years of psychiatric hospitals available depending on the state the availability of space and beds for new patients has drastically decreased.[24]

In July of 2022, the 988 number was created for those in America who needed mental health services so that they could have access to care and have help from anywhere or at any time. This number acts as the National Suicide Prevention Lifeline and was created to help combat the rising number of Americans who require mental health help particularly those dealing with suicidal thoughts or attempts and mental illness. 988 was created to help keep those in need from cycling endlessly between and or within emergency departments and the criminal justice system. Congress made history in 2022 by increasing support for the National Suicide Prevention Lifeline by a record amount of $77 million. The creation of this line helps prevent more people from being admitted into psychiatric hospitals by providing another outlet for immediate help and care. [25]

Types

Vilnius Psychiatric Hospital 1 The Republican Vilnius Psychiatric Hospital in Naujoji Vilnia (Parko g. 15), is one of the largest health facilities in Lithuania; built in 1902, official opening on 21 May 1903
Republican Vilnius Psychiatric Hospital in Naujoji Vilnia, one of the largest health facilities in Lithuania, built in 1902
The Art Nouveau-styled Röykkä Hospital, formerly known as Nummela Sanatorium, in Röykkä, Finland

There are several different types of modern psychiatric hospitals, but all of them house people with mental illnesses of varying severity. In the United Kingdom, both crisis admissions and medium-term care are usually provided on acute admissions wards. Juvenile or youth wards in psychiatric hospitals or psychiatric wards are set aside for children or youth with mental illness. Long-term care facilities have the goal of treatment and rehabilitation within a short time-frame (two or three years). Another institution for the mentally ill is a community-based halfway house.

Crisis stabilization

In the United States, there are high acuity and low acuity crisis facilities (or Crisis Stabilization Units). High acuity crisis stabilization units serve individuals who are actively suicidal, violent, or intoxicated. Low acuity crisis facilities include peer respites, social detoxes, and other programs to serve individuals who are not actively suicidal/violent.[26]

Open units

Open psychiatric units are not as secure as crisis stabilization units. They are not used for acutely suicidal people; instead, the focus in these units is to make life as normal as possible for patients while continuing treatment to the point where they can be discharged. Being within an open unit does not mean that the establishment has no control over a patient but more so that the patient is taking an active role in living similarly to how they would be outside of the hospital.[27] However, patients are usually still not allowed to hold their own medications in their rooms because of the risk of an impulsive overdose. While some open units are physically unlocked, other open units still use locked entrances and exits, depending on the type of patients admitted. During the creation of open wards an emphasis was made on ensuring that when in these units a patient feels as if the hospital is their own.[27]  

Medium term

Another type of psychiatric hospital is medium term, which provides care lasting several weeks. Most drugs used for psychiatric purposes take several weeks to take effect, and the main purpose of these hospitals is to monitor the patient for the first few weeks of therapy to ensure the treatment is effective.

Juvenile wards

Juvenile wards are sections of psychiatric hospitals or psychiatric wards set aside for children with mental illness. However, there are a number of institutions specializing only in the treatment of juveniles, particularly when dealing with drug abuse, self-harm, eating disorders, anxiety, depression or other mental illnesses.

As of 2020, the statistics of mental illness among inmates in jails and juvenile wards range from 15% to 20%. Because of this, many juvenile wards and prisons have opened an inpatient mental health unit within their facility.[28]

Long-term care facilities

Narrenturm in Vienna, built in 1784, is named for a German language phrase, meaning "fools' tower"; the hospital was among the earliest buildings designed specifically for the mentally ill.

In the United Kingdom, long-term care facilities are now being replaced with smaller secure units, some within hospitals. Modern buildings, modern security, and being locally situated to help with reintegration into society once medication has stabilized the condition[29][30] are often features of such units. Examples of this include the Three Bridges Unit at St Bernard's Hospital in West London and the John Munroe Hospital in Staffordshire. These units have the goal of treatment and rehabilitation to allow for transition back into society within a short time-frame, usually lasting two or three years. Not all patients' treatment meets this criterion, however, leading larger hospitals to retain this role.

These hospitals provide stabilization and rehabilitation for those who are actively experiencing uncontrolled symptoms of mental disorders such as depression, bipolar disorders, eating disorders, and so on.

In the United States long-term care facilities are used for individuals with severe and continuous mental health struggles. These hospitals provide a different form of care compared to other psychiatric hospitals; this type is designed to provide comprehensive care over an extended period of time, higher level of support and care, as well as heavy monitoring of patients.[31] Within these facilities the care can be better adapted to best fit each individual patient, this allows for a more patient centered focus on the form of care they are receiving.

Halfway houses

One type of institution for the mentally ill is a community-based halfway house. These facilities provide assisted living[32] for an extended period of time for patients with mental illnesses, and they often aid in the transition to self-sufficiency. These institutions are considered to be one of the most important parts of a mental health system by many psychiatrists, although some localities lack sufficient funding.

Political imprisonment

In some countries, the mental institution may be used for the incarceration of political prisoners as a form of punishment. One notable historical example was the use of punitive psychiatry in the Soviet Union[33] and other dictatorships.[34] .[35][36]

Secure units

In the United Kingdom, criminal courts or the Home Secretary can, under various sections of the Mental Health Act, order the detention of offenders in a psychiatric hospital, but the term "criminally insane" is no longer legally or medically recognized. Secure psychiatric units exist in all regions of the UK for this purpose; in addition, there are a few specialist hospitals which offer treatment with high levels of security. These facilities are divided into three main categories: High, Medium and Low Secure. Although the phrase "Maximum Secure" is often used in the media, there is no such classification. "Local Secure" is a common misnomer for Low Secure units, as patients are often detained there by local criminal courts for psychiatric assessment before sentencing.

Run by the National Health Service, these facilities which provide psychiatric assessments can also provide treatment and accommodation in a safe hospital environment which prevents absconding. Thus there is far less risk of patients harming themselves or others. In Dublin, the Central Mental Hospital performs a similar function.[37][38]

Community hospital utilization

Community hospitals across the United States regularly discharge mental health patients, who are then typically referred to out-patient treatment and therapy. A study of community hospital discharge data from 2003 to 2011, however, found that mental health hospitalizations had increased for both children and adults. Compared to other hospital utilization, mental health discharges for children were the lowest while the most rapidly increasing hospitalizations were for adults under 64.[39] Some units have been opened to provide therapeutically enhanced Treatment, a subcategory to the three main hospital unit types.[citation needed]

In the UK, high security hospitals exist, including Ashworth Hospital in Merseyside,[40] Broadmoor Hospital in Crowthorne, Rampton Secure Hospital in Retford, and the State Hospital in Carstairs, Scotland.[41] In Northern Ireland, the Isle of Man, and the Channel Islands, medium and low secure units exist but high secure units on the UK mainland are used for patients who qualify for the treatment under the Out of Area (Off-Island Placements) Referrals provision of the Mental Health Act 1983. Among the three unit types, medium secure facilities are the most prevalent in the UK. As of 2009, there were 27 women-only units in England.[42] Irish units include those at prisons in Portlaise, Castelrea, and Cork.

Criticism

Traverse City State Hospital in Traverse City, Michigan, U.S., in operation from 1881 to 1989

Psychiatrist Thomas Szasz in Hungary has argued that psychiatric hospitals are like prisons unlike other kinds of hospitals, and that psychiatrists who coerce people (into treatment or involuntary commitment) function as judges and jailers, not physicians.[43] Historian Michel Foucault is widely known for his comprehensive critique of the use and abuse of the mental hospital system in Madness and Civilization. He argued that Tuke and Pinel's asylum was a symbolic recreation of the condition of a child under a bourgeois family. It was a microcosm symbolizing the massive structures of bourgeois society and its values: relations of Family–Children (paternal authority), Fault–Punishment (immediate justice), Madness–Disorder (social and moral order).[44][45] Within the limitations of psychiatric hospitals during this period, individuals were mainly admitted due to social nonconformity, vulnerabilities, and social control. Asylums aimed to manage those deemed socially disruptive or considered “inconvenient.” This group primarily consisted of women, impoverished people, or those with language barriers.[46] [47]

Erving Goffman coined the term "total institution" for mental hospitals and similar places which took over and confined a person's whole life.[48]: 150 [49]: 9  Goffman placed psychiatric hospitals in the same category as concentration camps, prisons, military organizations, orphanages, and monasteries.[50] In his book Asylums Goffman describes how the institutionalisation process socialises people into the role of a good patient, someone "dull, harmless and inconspicuous"; in turn, it reinforces notions of chronicity in severe mental illness.[51] The Rosenhan experiment of 1973 demonstrated the difficulty of distinguishing sane patients from insane patients.

Rosenhan’s research questions the reliability of psychiatric diagnosis by showing how unstable the concept of insanity can be. In his pseudopatient experiment, Rosenhan demonstrated that once someone is labeled with "schizophrenia,” staff interpret all their behaviors through that diagnostic perspective. This underscores how institutional settings and biases influence mental health definitions. Interestingly, Rosenhan’s work revealed that real patients often recognized their own sanity more accurately than trained staff. This vulnerability in psychiatric authority raises the key issue of who holds the power to define sanity in institutional contexts and how this label affects the treatment individuals receive.[52]

Once someone was labeled as “insane,” they were placed in environments that were often harsh, overcrowded, and neglectful. Patients were typically confined to small, prison-like cells and frequently subjected to verbal and physical abuse by staff. These dehumanizing conditions extended to unsanitary living spaces and poor or rotten food, emphasizing the neglect characteristic of early institutional care. Accounts from later periods reveal that such conditions persisted into the mid-20th century, with routine abuse, long-term confinement, and lack of stimulation only coming to light through scandals and medical revelations.[53][54]

Franco Basaglia, a leading psychiatrist who inspired and planned the psychiatric reform in Italy, also defined the mental hospital as an oppressive, locked, and total institution in which prison-like, punitive rules are applied, in order to gradually eliminate its own contents. Patients, doctors and nurses are all subjected (at different levels) to the same process of institutionalism.[55] American psychiatrist Loren Mosher noticed that the psychiatric institution itself gave him master classes in the art of the "total institution": labeling, unnecessary dependency, the induction and perpetuation of powerlessness, the degradation ceremony, authoritarianism, and the primacy of institutional needs over the patients, whom it was ostensibly there to serve.[56]

The anti-psychiatry movement coming to the fore in the 1960s has opposed many of the practices, conditions, or existence of mental hospitals; due to the extreme conditions in them. The psychiatric consumer/survivor movement has often objected to or campaigned against conditions in mental hospitals or their use, voluntarily or involuntarily. The mental patient liberation movement emphatically opposes involuntary treatment but it generally does not object to any psychiatric treatments that are consensual, provided that both parties can withdraw consent at any time.[citation needed]

While there is a lot of criticism to the set up and the form of care psychiatric hospitals provide, there is the more prominent issue of stigmatization from other individuals and the communities surrounding these hospitals. There has been an increase in the stigmatization towards individuals who receive professional mental health care in psychiatric hospitals. Stigmatization has a major impact on not only the patients in these hospitals but also the clients of so-called alternative settings.[57] Having this stigma can cause future patients and individuals who need this care to be more hesitant to get the care due to the fear of future judgement and being a victim of this stigmatization. For example, Janna Herron, a previous patient at a psychiatric institution argues that psychiatric institutions are harsh and inhumane to patients and only cut them off from the outside world. She also says that psychiatric patients are stigmatized and that nobody wants to talk about the issues patients face.[58]

Some other criticism that can occur is by peers. This can have a direct impact on the patients. This alone can cause them not to feel as they can share or seek help from a professional mental health provider.

Historical criticism of psychiatric hospitals reveals that during the nineteenth and early twentieth centuries, women were admitted at disproportionately high rates. Women who diverged from traditional domestic roles, exhibited emotional expressiveness, independence, or were deemed unmanageable were quickly labeled insane and institutionalized without thorough assessment. Often, these women were hospitalized due to social nonconformity, issues like marital conflicts, poverty, or language difficulties, rather than genuine mental illness. These patterns highlight how psychiatric institutions served not only as medical tools but also as mechanisms of social control, with the pathologization of women’s behavior influenced by a male-dominated authority. This dynamic resulted in a higher rate of institutionalization among women whose actions challenged gender norms.[59][60]

A pattern of social regulation is evident in the way individuals engaging in same-sex relationships are treated, with sexuality often seen as a psychiatric disorder rather than a valid aspect of identity. Between 1910 and 1935, society regarded homosexuality as a fluid identity that could be altered through treatment. Due to this perception of same-sex relations, families and clinicians often chose institutional care for individuals experiencing conflicts with their same-sex desires. Many men were committed due to family pressure, reflecting how homosexuality, like women’s nonconformity, was seen as a deviation needing medical intervention. Early psychiatric institutions played a role in the historical mistreatment of LGBTQ people by pathologizing their identities and reinforcing the notion that deviation from heterosexual norms indicated mental illness, subjecting them to harsh and neglectful treatment in asylums.[61]

Undercover journalism

Alongside the 1973 academic investigation by Rosenhan and other similar experiments, several journalists have been willingly admitted to hospitals in order to conduct undercover journalism. These include:

Undercover journalism has played a role in highlighting issues in psychiatric care and advocating for people with mental illness. These investigations revealed conditions that included instances of abuse, neglect, and dehumanization. By reporting on social control, physical abuse, and the overrepresentation of marginalized communities in admissions, the coverage questioned the fairness of current institutional practices. This journalistic work contributed to changing public perceptions, supporting advocacy for patient rights, and promoting discussions around deinstitutionalization and improvements in psychiatric treatment.[70]

Criteria

When looking at the criteria for individuals who may need to be admitted into a psychiatric hospitals there are six things that are looked at to indicate the need for the hospital. These include mental status, self-care ability, responsible parties available, patients' effect on environment, danger potential and the treatment prognosis.[71] The need for inpatient care can change depending on the individual and the presenting issues that need to be addressed. Some other criteria can be if the individual is an immediate threat to themselves or others, this can be presented in something called a suicidal ideation. Some of the disorders or signs of someone who is in need of a psychiatric hospital are: major depressive disorder, suicidal ideation, schizophrenia, eating disorder, post-traumatic stress disorder, and many others.

See also

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