The humanitarian approach developed throughout history, in part as a reaction against the spiritual approach and its associated punishment of people with psychological disorders. Poorhouses and monasteries became shelters, and although they could not offer treatment, they provided some protective measures. Unfortunately, these often became overcrowded, and rather than provide protection themselves, they became places where abuses occurred. For example, society widely believed that psychologically disturbed people were insensitive to extremes of heat and cold, or to the cleanliness of their surroundings. Their “treatment” involved bleeding, forced vomiting, and purging. It took a few courageous people, who recognized the inhumanity of the existing practices, to bring about sweeping reforms. By the end of the eighteenth century, hospitals in France, Scotland, and England attempted to reverse these harsh practices. The idea of “moral treatment” took hold—the notion that people could develop self-control over their behaviors if they had a quiet and restful environment. Institutions used restraints only if absolutely necessary, and even in those cases the patient’s comfort came first.
Conditions in asylums again began to worsen in the early 1800s as facilities suffered from overcrowding and staff resorted to physical punishment to control the patients. In 1841, a Boston schoolteacher named Dorothea Dix (1802–1887) took up the cause of reform. Horrified by the inhumane conditions in the asylums, Dix appealed to the Massachusetts Legislature for more statefunded public hospitals to provide humane treatment for mental patients. From Massachusetts, Dix spread her message throughout North America and Europe.
Over the next 100 years, governments built scores of state hospitals throughout the United States. Once again, however, it was only a matter of time before the hospitals became overcrowded and understaffed. It simply was not possible to cure people by providing them with the well-intentioned, but ineffective, interventions proposed by moral treatment. However, the humanitarian goals that Dix advocated had a lasting influence on the mental health system. Her work was carried forward into the twentieth century by advocates of what became known as the mental hygiene movement.
Until the 1970s, despite the growing body of knowledge about the causes of abnormal behavior, the actual practices in the day-to-day care of psychologically disturbed people were sometimes as barbaric as those in the Middle Ages. Even people suffering from the least severe psychological disorders were often housed in the “backwards” of large and impersonal state institutions, without adequate or appropriate care. Institutions restrained patients with powerful tranquilizing drugs and straitjackets, coats with sleeves long enough to wrap around the patient’s torso. Even more radical was the indiscriminate use of behavior-altering brain surgery or the application of electrical shocks—so-called treatments that were punishments intended to control unruly patients.
Public outrage over these abuses in mental hospitals finally led to a more widespread realization that mental health services required dramatic changes. The federal government took emphatic action in 1963 with the passage of groundbreaking legislation. The Mental Retardation Facilities and Community Mental Health Center Construction Act of that year initiated a series of changes that would affect mental health services for decades to come. Legislators began to promote policies designed to move people out of institutions and into less restrictive programs in the community, such as vocational rehabilitation facilities, day hospitals, and psychiatric clinics. After their discharge from the hospital, people entered halfway houses, which provided a supportive environment in which they could learn the necessary social skills to re-enter the community. By the mid-1970s, the state mental hospitals, once overflowing with patients, were practically deserted. These hospitals freed hundreds of thousands of institutionally confined people to begin living with greater dignity and autonomy. This process, known as the deinstitutionalization movement, promoted the release of psychiatric patients into community treatment sites.
Unfortunately, the deinstitutionalization movement did not completely fulfill the dreams of its originators. Rather than abolishing inhumane treatment, deinstitutionalization created another set of woes. Many of the promises and programs hailed as alternatives to institutionalization ultimately failed to come through because of inadequate planning and insufficient funds. Patients shuttled back and forth between hospitals, halfway houses, and shabby boarding homes, never having a sense of stability or respect. Although the intention of releasing patients from psychiatric hospitals was to free people who had been deprived of basic human rights, the result may not have been as liberating as many had hoped. In contemporary American society, people who would have been in psychiatric hospitals four decades ago are moving through a circuit of shelters, rehabilitation programs, jails, and prisons, with a disturbing number of these individuals spending long periods of time as homeless and marginalized members of society.
Contemporary advocates of the humanitarian approach suggest new forms of compassionate treatment for people who suffer from psychological disorders. These advocates encourage mental health consumers to take an active role in choosing their treatment. Various advocacy groups have worked tirelessly to change the way the public views mentally ill people and how society deals with them in all settings. These groups include the National Alliance on Mental Illness (NAMI), as well as the Mental Health Association, the Center to Address Discrimination and Stigma, and the Eliminate the Barriers Initiative. The U.S. federal government has also become involved in antistigma programs as part of efforts to improve the delivery of mental health services through the President’s New Freedom Commission (Hogan, 2003). Looking forward into the next decade, the U.S. government has set the 2020 Healthy People initiative goals as focused on improving significantly the quality of treatment services (see Table 1.2).
Table 1.2 Healthy People 2020 Goals
In late 2010, the U.S. government’s Healthy People project released goals for the coming decade. These goals are intended both to improve the psychological functioning of individuals in the U.S. and to expand treatment services.
• Reduce the suicide rate.
• Reduce suicide attempts by adolescents.
• Reduce the proportion of adolescents who engage in disordered eating behaviors in an attempt to control their weight.
• Reduce the proportion of persons who experience major depressive episodes.
• Increase the proportion of primary care facilities that provide mental health treatment onsite or by paid referral.
• Increase the proportion of children with mental health problems who receive treatment.
• Increase the proportion of juvenile residential facilities that screen admissions for mental health problems.
• Increase the proportion of persons with serious mental illness (SMI) who are employed.
• Increase the proportion of adults with mental disorders who receive treatment.
• Increase the proportion of persons with co-occurring substance abuse and mental disorders who receive treatment for both disorders.
• Increase depression screening by primary care providers.
• Increase the proportion of homeless adults with mental health problems who receive mental health services.