It’s probably safe to say that psychiatric hospitals have gotten a bad rap. They have often been inaccurately depicted in films, TV and other media as dark, scary institutions where deranged patients are forcibly medicated, put into straitjackets, or mistreated by cruel and sadistic staff.
Even worse is the demeaning language which has been used to describe these facilities: “loony bin,” “nuthouse,” “bedlam,” or “lunatic asylum.” Just to be clear, these terms are now considered inappropriate and unacceptable.
When I was nearing completion of my doctoral training in clinical psychology, I applied for and accepted a job at a large public psychiatric hospital. I had always envisioned myself as a psychologist who would work in private practice. But I thought the hospital would be an interesting job for a year or two. So it’s still somewhat surprising to me that I ended up working there for over 24 years. Let me tell you about my journey.
Eastern State Hospital in Lexington, Kentucky opened its doors on May 1, 1824, and it’s still open to this day, 200 years later. It is the second oldest psychiatric hospital in the United States. (The only one which predates it is in Williamsburg, Virginia.) When it first opened, it was the “Fayette Hospital” and it has had over a dozen other (now politically incorrect) names through the years, including the “Lunatic Asylum” and the “Eastern Kentucky Asylum for the Insane.”
The history of the hospital closely mirrors how mental health care has evolved and changed over the last two centuries. For its first 130 years, patient care at the hospital was largely custodial in nature, with no modern treatments. It was not uncommon for patients to stay at the hospital for decades. Patients engaged in farming, had a dairy barn, and raised poultry. For many years, local dignitaries were invited to a fancy “Lunatic Ball” in the hospital’s ornate ballroom. Scores of patients were buried on the hospital’s grounds.
By the 1940’s there were over 2000 residents at the hospital. In the mid-1950’s the “modern” era of psychiatric treatment arrived with the advent of Thorazine, the first medication proven effective in treating psychotic conditions, including schizophrenia. Also, of personal interest to me, the first psychologist was employed there in 1950.
The 1960’s and 70’s saw the “deinstitutionalization” movement, designed to get patients out of the large psychiatric hospitals and into less restrictive community-based mental health programs, following passage of the Community Mental Health Act, signed into law by President John F. Kennedy in 1963. Through the 1970’s and 80’s, many new and effective medications and psychotherapeutic approaches were introduced.
When I arrived at Eastern State as a young, newly minted Ph.D. clinical psychologist in the early 1990’s, there were less than 300 patients, spread across 10 treatment units. The term “ward” (as in “psych ward”) was still in use at that time, but was soon discontinued in favor of the term “unit.”
The facility encompassed several buildings from different eras. Most of the buildings used for patient care were constructed in the 1940’s or 50’s, but the administration building (pictured) dated back to the 1890’s. A more modern building housed a full-size gym and a spacious cafeteria. The facility also included a pharmacy, library, laundry, recreation center, pottery kiln, a greenhouse program, X-ray, medical laboratory and a dental clinic.
The facility was clean, but a bit spooky in some areas, as there were still underground tunnels connecting several of the buildings. Climate control was not always a sure thing, given the aging steam heating system. Since older physical plant systems tend to break down more frequently, the maintenance staff were always busy.
When I started working at the hospital, there were still “smoking rooms” on each unit, where patients could go and smoke a cigarette. Due to the less than optimal ventilation systems in these rooms, they were soon phased out. Then patients were escorted outside by staff several times a day for “smoke breaks.” Patients with unsupervised outside time could often be seen walking around the grounds or sitting under a shady tree with cigarette in hand.
Although used in the distant past, I never saw a straitjacket. However, if patients were uncontrollably aggressive, they could be placed on a bed equipped with wrist and ankle restraints. These restraints used to be made of leather. Current versions, now used much less frequently, are made of nylon with overlapping Velcro bands. All patients in restraints were continuously monitored by staff in private observation rooms.
The hospital was a busy place. Well over 2000 patients were admitted each year, as Eastern State served almost half of the counties in Kentucky. Three other state-operated or affiliated hospitals served the other regions of the state. Most patients were admitted on a court order, meaning they met the criteria of presenting with symptoms suggestive of a mental illness and displaying behaviors indicating a significant risk of harm to themselves or others.
For almost 14 years, I served as the program director of the acute admission unit. The vast majority of the patients were admitted to this unit. Patients were discharged from this unit unless it was anticipated they would require a stay of longer than about 10 days. If so, they would be transferred to one of several longer-term units.
Therefore, our job was to conduct a thorough assessment, assign a tentative initial diagnosis, and begin appropriate treatments, including medication, education, and therapy. Another huge focus was discharge planning, and connecting patients with community resources for further mental health care, housing, employment, and medical treatment.
In addition to coordinating the treatment team and the flow of patients through the unit, I also conducted psychological testing (often for diagnostic clarification) and provided psychotherapy. Since the hospital was affiliated with many area universities, we trained countless students from many different health care fields.
We served patients who were 18 or older, and with all types of psychiatric diagnoses. Most had low incomes, some were unemployed or homeless, and many received health care support through governmental Medicaid or Medicare insurance programs. Many were sent from local jails after displaying mental health concerns. A significant number of the patients had depression, anxiety, and substance use disorders. It was not uncommon to see people with borderline or antisocial personality disorders. Most of these patients were admitted following a crisis and had short stays in the hospital.
Another group of patients had more serious and persistent mental illnesses, such as schizophrenia or bipolar disorder. They tended to have multiple hospitalizations and would sometimes stay in the hospital several weeks or even a few months. A very small number of patients might stay longer than a year, but the days of living one’s life in the hospital was now a thing of the past.
Other patient types included older adults with cognitive disorders such as dementia, people with intellectual disabilities who displayed impulsive or aggressive behaviors, and those with pending criminal charges whose competency to stand trial had been called into question.
The work was fast-paced and demanding. The admission unit often had the feel of an emergency room, with several admissions and discharges each day. Since many of our clinical staff didn’t work on the weekends, it wasn’t unusual to return to work on Monday morning to find a dozen or more new patients who had been admitted since Friday afternoon.
At its peak, our unit was staffed with four psychiatrists, four social workers, two psychologists, and round-the-clock nursing staff, along with various other therapists, dietitians, pharmacists and more. We provided an array of groups on topics such as managing depression and anxiety, substance abuse education, and a variety of coping skills.
Despite the aging physical facility, the care provided to patients was compassionate and effective. The staff who work in these facilities tend to have a true calling for the work and the treatment teams bond together and feel almost like families. It was always gratifying to see many patients improve and successfully transition back to their home communities.
At the same time, it was heartbreaking to see the individuals with the most severe symptoms who showed little response to treatment and who were caught in the “revolving door” of frequent discharges and readmissions. I saw many courageous families struggle to help their loved ones, while other patients had little or no family support.
For many years, there had been discussions about renovating the hospital or building a new facility. Also, around 2005, we decided to update the hospital’s treatment programs to include an emphasis on an approach to care that, at that time, was not frequently used: recovery.
Little did I know how over the next several years this decision would change the entire landscape of our treatment programming and that we would ultimately end up in a brand new state-of-the-art facility. To read the second part of my 24-year Eastern State journey, click here.
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