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Asylum: Inside the Closed World of State Mental Hospitals
Reviewed by Joel Yager, M.D.
Am J Psychiatry 2010;167:1539-1539. doi:10.1176/appi.ajp.2010.10091262
View Author and Article Information
Denver, Colo.

Book review accepted for publication September 2010

The author reports no financial relationships with commercial interests.

Accepted September , 2010.

Copyright © American Psychiatric Association

This illuminating and evocative book features marvelous photographs and edifying discussions by Christopher Payne, an award-winning photographer trained as an architect who specializes in documenting vanishing and forgotten architecture and industrial archeology. Here, he records, validates, and honors both the magnificence and the horrors that were embedded in our nation's large, now disappearing, state mental hospitals. Initially inspired by a suggestion from a psychiatrist friend that he might want to visit Pilgrim State Hospital in New York, Payne visited 70 institutions in 30 states, from 2002 to 2008, photographing splendid exteriors, magisterial grounds, endless corridors, collapsing interiors, peeling walls, and corroded pipes that portray both the grandeur and lofty intentions as well as the industrial-strength dehumanization through which millions of Americans passed, largely from the mid-19th century through the latter decades of the 20th century. These beautiful and harrowing pictures witness a grand, ultimately failed, project that has largely come to an end.

In his eloquent and humane introductory essay, previously published separately in the New York Review of Books (1), Oliver Sacks reviews the good, bad, and ugly of the state hospital era. He lauds Payne as a "visual poet" capturing the beauties and the evolution, and sad devolution, of these enormous enterprises. Payne's photographs see through the deteriorating facades to what was originally intended by the high-minded physicians, nurses, architects, public servants, and citizens who conceptualized moral treatment as the best available method for caring for the mentally ill in the early and mid-19th century. These were interiors of grandeur—large, open, full of light and air and placed in elegant, often palatial, buildings with magnificent grounds, projected to be places of true asylum. So these commanding institutions, in many instances representing top-of-the-line Classic and Victorian architecture, were usually built remotely, purposefully away from large, noisy, and congested urban concentrations, and served as places of actual refuge for countless individuals and their families. They were meant to be fully contained and self-sufficient institutions, and for many decades until well after World War II they were just that: communities that produced virtually all their own consumables, from food to clothing, based on the productive labor of the patients, many of whom found meaning in the work they were expected to contribute to their well being. And these places were huge. At its peak, for example, Pilgrim State Hospital housed about 14,000 patients.

That many of these institutions deteriorated over the years and degraded into underfunded human warehouses reflected how the dedication, zeal, humanism, charisma, and political persuasiveness of their initial well-intentioned developers, caretakers, and superintendents failed to sustain. The legacies of the state hospital era—peaking in the late 19th century through the 1950s and 1960s, when hospitals began to discharge patients to the community in large numbers, down-size, and, in many cases, close entirely—are complex. The good aspects of moral treatment, where patients were managed by kindly staff out in the country, in peaceful places that actually offered the space, time, and respite to heal, represent the most noble of psychiatry's past days. In contrast, the bad and the ugly of socially neglected, dehumanizing institutions, where patients were stacked, sometimes abused, sometimes neglected, and sometimes subjected to degrading, unethical, and occasionally violent "treatment" protocols prior to the modern era, are the stuff of shame.

On balance? A patient discharged from Bronx State Hospital in the wake of deinstitutionalization and the oversold community mental health movement, as quoted by Sacks (1), nails the dilemma: "Bronx State is no picnic but it is infinitely better than starving, freezing on the streets, or being knifed in the Bowery."

All these themes come together in this excellent coffee-table gift for the photography and/or psychiatric history buffs on your list. And, from my perspective, all teachers and students of the history of psychiatry as well as community psychiatry and psychiatric treatment settings would benefit from perusing these pages and from reflecting on and discussing the many unanswered questions that still abound about how to provide decent moral care for patients. Like penetrating films, these photographs leave indelible impressions, convey haunting images and zeitgeist, and raise numerous questions.

What next? Payne's outstanding sensibilities might be fruitfully invested in portraying post-state hospital treatment settings. His talented and penetrating eye would undoubtedly help us better feel as well as think about the places where many of today's chronically mentally ill individuals are domiciled and reside: single room occupancies, homeless shelters, jails, and the streets.

Sacks  O:  The Lost Virtues of the Asylum.  New York, New York Review of Books , September 242009
References Container


Sacks  O:  The Lost Virtues of the Asylum.  New York, New York Review of Books , September 242009
References Container

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