The Eclipse of the State Mental Hospital: Policy, Stigma, and Organization (review)

While state hospitals have shrunk in size and relative importance in recent years, George Dowdall argues that their eclipse is only partial. Despite bitter attacks, relatively few have closed. Dowdall, a sociologist, attributes this remarkable durability to organizational form. From the early nineteenth century to the present, he argues, state hospitals have been “maximalist” institutions. As such, they have been difficult to change and to eliminate.

It is tempting for historians impatient with sociological abstractions to bypass Dowdall’s discussion of organizational theory in favor of his case study of the New York State institution now known as the Buffalo Psychiatric Center. However, Dowdall’s efforts to situate the Buffalo experience in a larger context—both historiographic and social-scientific—are worth attention. In his survey of the historical literature, he notes its focus on the nineteenth century; in contrast, sociologists have emphasized the mid-twentieth. By studying Buffalo from its opening in 1880 to the early 1990s, Dowdall attempts to meld these two stories into a continuous public policy narrative.

As mentioned already, Dowdall argues that the concept of mental hospitals as “maximalist” institutions applies to their entire history. “Maximalist” institutions meet five criteria: they are expensive to open and to maintain; they provide almost all of their own resources, from power plants to surgical wards; they change very slowly, if at all; they occupy secure, easily defended niches; and they face relatively little competition (pp. 23–24). During the past four decades, state hospitals have shrunk drastically in size, but, Dowdall argues in his first chapter, they continue to be “survivors” (p. 49). He concludes with a similar comment: “Barring extraordinary therapeutic breakthroughs, the well-being of many of the most seriously mentally ill . . . [will continue to be] tied to the state hospital” (p. 209).

Most of the intervening pages focus on the history of a single hospital, the Buffalo State Asylum. Opened in 1880, ten years later it became the Buffalo State Hospital, and in 1974, the Buffalo Psychiatric Center. While the renaming signified shifts in mission, Dowdall sees changelessness as the institution’s most consistent quality over time. In support of this argument, he (with Janet Golden) offers an interesting analysis of more than eight hundred photographs of Buffalo Psychiatric Center, taken between 1890 and 1945. For the entire period, there are almost no medical images or pictures of the physicians who “ruled” over the institution. Photographs of patients, even when engaged in occupational therapy, suggest “the essential torpor of asylum life” (p. 130). Not surprisingly, overcrowding also is a common theme; however, even those familiar with the history of psychiatric institutions may be startled by the (regretfully undated) pictures of male patients crowded onto a locked porch (p. 126) and of a ward for infirm geriatric patients, crammed with almost-touching rows of beds (p. 132).

From time to time, Dowdall supplements his Buffalo narrative with larger-scale quantitative data. Particularly interesting are his “event history” analyses of the opening and closing of state hospitals in the United States. He finds the number of physicians in a state (highly correlated with population size) to be the only statistically significant predictor of nineteenth-century openings. Level of urbanization also is important, but levels of immigration and industrialization are not. In the late twentieth century, the only statistically significant predictors of closing have been deinstitutionalization (but not the growth of alternative institutions), industrialization, and unionization.

Reading Dowdall, historians may want more psychiatric history, and social scientists more policy analysis. Multidisciplinary work seldom satisfies everyone, but those who attempt it are to be commended: by introducing specialists in one field to the scholarship and methods of another, they not only raise new questions but also suggest new ways of answering them.