Closing the State Mental Hospitals

by Thomas J. Scheff (September 2012)

This is the story of my studies of mental hospitals. My first was Stockton State Hospital, in northern California. My involvement began when I was still a graduate student in sociology at UC Berkeley. The Department of Mental Hygiene in Sacramento made available several six-month fellowships to study mental hospitals. I was chosen to be one of Fellows, and, in turn, I chose to study Stockton State, beginning August 1, 1958. This study was the basis for my Ph.D dissertation. As it turned out, the study raised questions for me that I was able to examine more fully in the research I did on the Wisconsin mental hospital system, to be described in a later essay.

Why Stockton, when I knew nothing at all about the hospital there? For that matter, I had no training whatever in the study of mental illness. I was trained in a sociology department to be a social psychologist. As I remember, there were two main reasons for Stockton. First, it was relatively close to Berkeley, less than a two-hour drive. If I needed to consult with my advisor, a trip wouldn’t take long. The second reason was even slighter: I had taken a job as an assistant professor in sociology at the U. of Wisconsin in Madison beginning Jan. 1, 1959. Stockton was on the way. I had six months to study the hospital.

Stockton State

My family and I packed up our goods and drove from Berkeley to the apartment we had rented in Stockton. After introducing myself to the main administrators of the hospital, I began my study by casual observation on the two admission wards, one for men, the other for women. It didn’t take long for me to realize that I would be able to understand most of what I saw there. It was like the general hospitals I had seen, with doctors and nurses diagnosing and treating incoming patients.

Patients that responded to treatment were released, as were some of those patients who didn’t respond, but whose family had them released. The patients with little or no response were also rapidly moved out of admission to other wards. Once on these back wards, the rate of release was much slower. When it did occur, it was usually because the patient’s family brought it about, rather than the hospital. This will be an important issue, to be described below.

Stockton was a sizable hospital in those days, with perhaps twenty-five wards and a thousand patients. There were many back wards, so I began to visit them. However, after only a few visits on several wards, I was puzzled because I didn’t understand what I saw. As far as I could tell, there were no doctors or nurses, and there was no treatment. Patients roamed the halls or sat in chairs all day long. The staff was made up of “psychiatric technicians,” untrained persons who kept order.

I later found out that there was a physician nominally in charge of each ward, and a social worker. However, I seldom saw either on the ward, nor a nurse either. I learned that the doctors and social workers had offices in the administrative building, and visited their ward only under unusual circumstances. If most of the patients are not treated by doctors and social workers, what was going on?

I made an appointment to talk with my advisor, the sociologist Erving Goffman, at his office on the Berkeley campus. When I got there I told him my dilemma. As I began to describe some of the sights I had seen, some abusive, he interrupted me:

“Read Lemert.”

Me: “Lemert? What’s that?”

Goffman: “It’s a book called Social Pathology. There’s a chapter on mental illness.”

When I tried to resume the conversation, he sent me on my way. For my 150 mile round trip, I was awarded only ten minutes. However, he was right about Lemert. After reading his chapter, I had a way of understanding what I had seen. The chapter was a brief description of the sociology of labeling: the social and psychological effects on a patient of being officially diagnosed as a deviant. Since deviants lose many of their rights as persons, I could better understand the way they were dealt with by the techs.

I was encouraged with the thought that now I might learn in detail more about the workings of these wards. Oddly, Goffman didn’t refer me to his own article on total institutions (1958), which would have helped as much or more than Lemert. Like me, he was an observer on the wards of a mental hospital, St. Elizabeth’s in Washington D.C. Perhaps he didn’t want to prejudice me. 

After reading Lemert, I spent almost six months observing, mostly in one one female ward, E-5. Before I got there, some of the staff had told me it was the end of the line for women patients who didn’t respond to whatever treatment was available on other wards. I was on E-5 for 10-12 hours a day, 5 or 6 days a week. I made a practice of arriving on the ward before noon and leaving at night, so that I could observe both the day shift of techs (8-4) and the night shift (4-12).

In addition to observing, I also had many conversations with techs and with patients. I was a new and unusual presence on the unit; they spoke to me about themselves and/or the ward. The head tech, Ruby, often asked my opinion, and I frequently asked her, other staff, and also patients about various issues. I quickly realized that the staff provided virtually no treatment: their main goal was to keep order, which often meant punishing patients who didn’t obey.

I came to believe that the back wards of the hospital (all but the two admission wards) were warehouses for people rejected by their society, basically the poor and the old. At the time there was also another kind of resident who were young, poor, and spoke no English. At one point during my stay, I noticed that sheets, blankets and pillowcases were changed frequently on all the wards. I was curious, since laundry for a thousand beds could be very expensive.

The techs, however, told me that they got the laundry done by patients. I had to take a look to see how that worked. I found that the huge facility was run entirely by about six young male immigrants from China who spoke no English whatsoever. I couldn’t question them without an interpreter, so I spent several days watching in the laundry. Their operation ran smoothly, since they could talk to each other. Except for the location, no observer would have suspected that these men were supposed to be mentally ill.

Crisis

I hadn’t been on this ward long when I had a crisis of conscience. An attractive young patient had been sent to E-5 directly from the admissions ward, a very unusual placement. Why?

When I spoke to her, the first thing I noted that she didn’t seem to have symptoms. She spoke clearly and intelligently about the rough treatment she had received when taken to the hospital, and, since she kept complaining in the receiving ward, the treatment she received there also. On the ward, she was polite to everyone, but she was outspoken about what she thought of as her unjust retention.

It didn’t take the staff long to respond to what they considered her misbehavior. She was tied to a pillar in the central meeting room, bound hand and foot. The techs would ridicule her talking as they passed by, and soon, some of the patients began to do the same. At first she met the ridicule patiently, by telling part of the story from memory of a classic novel she had read, Les Miserable, how a man whose family was starving was sentenced to life imprisonment for stealing a loaf of bread.

When I returned at noon the next day, she was still tied to the post. But now she was utterly different, maniacal. The constant ridicule and mistreatment had broken her spirit. I had two strong thoughts: the techs have to be stopped. The second thought was, I will never forgive myself if I don’t tell.

After a sleepless night, I decided to make another appointment with Goffman. So back to Berkeley I went. This time he heard me out. Then he said, “That’s bad, but I’ve seen worse. You have to be a lemmelke.” I said, “What’s that?” He said, “Its Yiddish for a little lamb.” He meant I must keep my mouth shut. I was afraid he would say that. So the whole way back to Stockton, I was thinking through how I would quit.

However, when I got back to the ward, the problem had already been solved. When one of the social workers, Jean Harwood, heard that I was making my home on E-5, she moved her office there. Her introduction to the unit was to see the patient who was tied to the post being ridiculed by staff and patients. She immediately squealed, leading to a censure for the ward’s nominal boss, Dr Green, and the head tech, Ruby. I didn’t have to tell. However, the censures seemed to be weak, since little had changed. But my conscience was satisfied: I didn’t have to tell.

One change that might have resulted from the incident was that the hospital had insisted that all units have a weekly group meeting between the day staff and all patients. It had a good name, Therapeutic Community, but it had no effect whatever on E-5. The patients had been intimidated by the rough treatment of the outspoken patient described above. The staff simply used the meetings as one more way of keeping order and obedience on the ward.

The social worker Jean Harwood came to the rescue in another case of staff abuse of patients that occurred just before my study ended. When two patients died of pneumonia, I became suspicious. I knew both patients; they were old, but strong and healthy. So I began chatting with my best patient informant, who was also old but strong. She became nervous when she realized the direction my questions were taking.

She told me not now. She would talk to me, but only when no one was around. We found a safe spot next day. She said that they died from the punishments the staff inflicted on them. Apparently they were making complaints about the staff. When it was clear they meant to persist, they were put into one of the solitary rooms. There was a large room with 8 such rooms, each much like a prison cell. Both were tied to the bed so that they couldn’t move and covered with a sheet. They must have been fed by hand by the techs. At the end of the night shifts, the techs drenched them with cold water and opened the nearby windows. It was late fall and there were cool winds at night.

My informant thought that I didn’t fully believe her story, so she named one of the cells for me to peek into. I waited until I would not be seen in solitary cell room. There was a patient bound to the bed, covered with a sheet. Once again I felt that I surely must tell.

I thought it might help if I talked to Jean Harwood about what to do. When I told her, she looked into it, then reported the incident, not just to the hospital administration, but also to the Dept. of Mental Hygiene. I believe that this time there were significant repercussions. I am not sure, however, since this event occurred near the end of my stay at the hospital.

The rest of this essay will be observations that give the flavor of the E-5 staff’s attitude toward the patients on E-5, which I observed most intensively. They exaggerate the abusiveness of the staff, but only slightly. The staff attitudes of all the other mental hospital wards I later observed were very similar. The only exceptions were the wards of Schenley Hospital, near London, in which neglect, rather than abuse, was the most prominent feature.

On E-5, it was the custom of the afternoon shift attendants to sit together before the entrance to the ward office during a quiet period of the day. With the exception of two of the attendants who manned an outer office, the entire afternoon shift sat in a semi-circle, guarding the office and “charge” (the person in charge)who sat inside. Sitting in this position, they talked among themselves and watched the patients. If the doctor was in the office, they kept the patients from seeing him. Very few patients approached this barrier. A patient who did come to this group, with a request for a dental appointment, for example, was usually teased or taunted until she gave up. I saw this happen many times. Under these conditions a civil conversation between patient and staff members was usually impossible.

The entire shift participated in this activity, including the most reform-oriented staff members. In order to honor a patient’s request in a situation like this, a staff member would have had to oppose, however gently, another staff member in the presence of a patient. Since this was counter to one of the unspoken rules of the staff, it seldom occurred. Similar kinds of control are exercised in groups of adolescent boys. All of the boys, not only the leader, use the epithet “chicken” for the person who does not conform. Staff members on the afternoon shift similarly, kept each other from consorting with patients, even when the shift leader was absent.

Staff members were controlled through the operation of sanctions such as those used by the leadership, and through informal measures such as gossip and censure in face-to-face interaction. Of greater importance than sanctions in the control of the staff, however, were rationalizations that were shared by the staff members. Unlike the patients, the staff members were not overwhelmed by the operation of sanctions; staff members could themselves strike back against the shift leadership if provoked. That they seldom did so was the result of not only of the power of the leadership, but also of the fact that the bulk of the staff was caught up in the system of rationalizations which prevented organized opposition. Even in wards where a stable reform group existed, the actions of this group were highly variable and inconsistent. The rationalizations which kept this group and similar groups on other wards captive are discussed below. Four types of rationalization will be considered: patient labels, ridicule of patients, fictions concerning patients, and anecdotes.

The use of convenient labels for the patients operated to justify and maintain traditional hospital practices. Terms such as “vegetable”, (a withdrawn patient) which were at once an attack on the patient’s moral worth, and a justification of inactivity of the staff, were used by most of the staff in referring to a patient, rather than a more neutral psychiatric term. This particular term, “vegetable” was no longer used openly, since its use had been forbidden by the administration. In the informal discussions in which most ward business was conducted, however, it was still used.

There were two main reasons for its continued use. The nursing staff lacked familiarity with psychiatric terminology. In addition, many felt that the diagnostic terms were pretentious, and irrelevant to hospital problems. There was some justification for this feeling. Although an official psychiatric diagnosis was attached to each patient, little use was made of it in the entire course of treatment. The nursing staff thought of diagnosis as more of the hospital formalities which had little relation to actual hospital practices. Rather than using psychiatric terminology, the nursing staff described patients either in terms of organic conditions, or in terms of their ward behavior. Examples of the former usage were “ep” (epileptic) and “lobotomy” (as in the statement by one of the reform group: “You will never get anywhere with her, she’s a lobotomy.” That is, the patient was brain-damaged and therefore permanently unresponsive.) Further examples were: “feeble” (feeble minded), “luie” (luetic: a patient with syphilis), “drug addict”, and “alcoholic.” Examples of labels based on behavior were” “pest,” “nuisance,” “manic,” “suicide,” “untidy,” (incontinent), “promiscuous,” “runaway,” “hebie” (hebephrenic-silly), “queen bee” (referring to patients who tried to keep themselves attractive through the use of cosmetics, dress, and so on. Usually this term has the connotation of persons who thought themselves superior to the other patients), “withdrawn,” and “combative.”

All of these terms carried disparagement, both for the individual patient and for the patients as a group. Often, however, these terms were used not to disparage, but simply for convenience. The ward culture possessed no other generally accepted terms which did not disparage. In these cases, the patient’s low status was reaffirmed even when there was no intention to do so.

There is a great deal of nervous laughter in the mental hospital ward. Staff members faced with a constant array of immediate, yet recurring problems frequently tell jokes at the patients’ expense. The types of humor considered here are: “passing” jokes, ridicule of patients, and other humor.

“Passing” jokes refer to real or pretend mistaken identities, mistaking a patient for a staff member, or vice versa. In the staff dining room an A-1 attendant who was first in line with a group of attendants said to the staff food-handlers: “I get so tired of taking these people (i.e. patients) to eat.” Jokes about letting staff members and others on and off a locked ward with a key are extremely frequent. These sometimes have a hostile edge. On my first visit to a men’s ward, when I asked to be let off the ward, one attendant said:

“These people come in and then they want to get out right away.”

The other attendant said:

“You have to go through the (disposition) clinic if you want to get out, just like the others.”

Staff members often complained that the dress of some of the physicians make it impossible to distinguish them from the patients. This declaration was usually met by a smile or laughter from other staff members present, as if it were malicious to admit such a mistake for someone with so high a status as a doctor. The humor in this situation was based on the unstated assumption of the lowly, undesirable status of the patient. The fact that staff members laughed at jokes like these was an inadvertent affirmation of these underlying assumptions.

Ridicule occurred, even on front wards, when a patient’s record was read to the staff for the first time in ward “intake” conferences. Some typical situations which occurred in A-1 “intakes”:

1. Doctor: “We have a liberal dose of psychosis this morning. This patient has always thought she was Honeybear Warren. Better write to Warren and tell him he is a bigamist.” (Laughter)

Attendant: “Married to a woman 35 years and then…” (She laughs)

The patient was brought in. She told her a story and was taken out. Turning to the social worker after the patient left, the physician said: “Would you check on this?” (Laughter)

2. Another patient, an American Indian. The physician read from her record: “She was doing a war dance on Highway 99. (Laugher) She was heading West on the wrong side of the road.”

Attendant: “All good Indians go West.” (She laughs)

3. Another patient; the doctor read from her record: “She sets off fire alarms.” (Laughter) “She thought her hotel was full of rubber snakes and some of them aren’t rubber.” (Laughter)
4. This patient was a middle-aged woman with her hair in ring curls. The patient had finished her story of plots on television to “get her,” men watching her doing the wash, and planning earthquakes when she dried her clothes. At this point in her story, she interjected: “Things like that would make most people mentally ill. Thank God I’m not crazy.” At this point, staff members coughed, covered their mouths, and took other steps to avoid laughing out.
5. After the “intake” was over, during which one patient had said that she was Greg Sherwood, an attendant said to another: “Do you think Pat Boone looks you in the eye when he’s on TV?” (They both laughed)

On E-5 there was a large body of beliefs about patients which were based partly on experience, but depended mostly on being transmitted from employee to employee. Some of these beliefs were stated frequently and openly; 1) epileptics have a very bad disposition: there is an “epileptic” personality consisting of being willful, stubborn, changeable and deceptive, and so on. 2) A series of beliefs centered around the notion that patients are like children; and that patients are happy. 3) Female patients are wilder and stronger than male patients. 4) Persons lose all sense of morality when they become mentally ill. This conviction was related to staff beliefs about patient sexuality. Other convictions are firmly held, but were seldom discussed openly. Two examples will illustrate the tenor of a large body of similar beliefs.

1. One attendant told me that the reason there was so much incontinence on E-5 was that when a person becomes mentally ill, he loses control of the sphincter. She said that the doctor would agree to that. I said why is it, then, that there is so much incontinence here and so little on some of the other wards? She said: “Because our patients are so much sicker.”
2. One of the attendants on A-1, a person who I would say was an unusually competent nurse and was sympathetic with them (although she “talked tough” with the other attendants) told me, as an aside from the main topic of conversation, that mental patients have a distinctive odor: “You get in the showers with them sometimes. It just pours off them.”

On E-5 such beliefs were firmly held by most of the staff. Since practically all of the staff shared these beliefs, they were consensually validated. On A-1, however, these beliefs were much more of an individual matter, so that the staff member was much less certain of their validity.

Of all the aspects of patient behavior discussed by the staff, the most prominent was the patients’ sex life. The nursing staff had the strong belief that patients’ sex life was abnormal and should be strictly regulated. In an A-1 staff conference, the misbehavior of a patient on the grounds was the topic of discussion. A number of rumors of misbehavior by this patient had been discussed, with much heat, but no resolution. The argument appeared to be heading for a decision, however, when a student nurse indicated that she was an eye-witness to the incident.

Student nurse: “___ was carrying on with a male patient near the tennis court” (Said with rolling of eyeballs and gestures indicating a serious offense.)

Social worker: “What was she doing?”

Attendant: “That’s just like ___, I wouldn’t put it past her.”

At this point there was a great deal of tsk-tsking, head wagging, and giggling. Staff members began to whisper to each other about other aspects of “the patient sex problem.”

Social Worker: “Just exactly what was she doing? Were they having intercourse?”

Student Nurse: “No.” (This came as a surprise, since everyone had assumed that had been what she meant) “They were just kissing, but ___ was the aggressor; he was trying to bring her back to the ward, and she kept dragging him back.”

Social Worker: “Maybe she was out of line, but there was nothing terribly wrong About what you saw, which is the idea you gave us at first.”

Student nurse: “I guess what she was doing was alright, but not for a patient in a State Mental Hospital.”

The student nurse felt, and the other staff strongly concurred, that such behavior was inappropriate for a person with the status of a patient. Although patients occasionally were promiscuous, there was no factual basis for most of the stories that circulated though the staff.

Staff meetings were created by the administration so that the entire ward staff could participate in making ward policy. In the front wards, most of the policy discussions were firmly in the hands of the physicians and other professionals. Ward problems and case materials were usually discussed within the framework of psychiatric and psychological principles. In these circumstances, participation of the nursing staff in policy making was limited.

The situation in the back wards was quite different, however. In these wards, the physician was always a general practitioner, rather than a psychiatrist. Psychologists and social workers were rarely present. Since the staff members themselves had little training in psychiatric nursing, formal principles were seldom referred to. Each ward had to evolve its own mode of discussion for reaching policy decisions, or resolving problems that arose from patient’s behavior. The staff of E-5 developed a method of handling these problems which was based on precedent. Without formal training, and with little explicit guidance from the administration, the staff discussed each problem concretely, in terms of their past experiences with patients.

When the patient Rose Ryan continued to smoke illegally, and all methods of control had been exhausted, her case was discussed once again in the staff meeting. When the discussion had reached an impasse, an attendant said:

“What about Charlene, didn’t we have the same problems with her stealing? What did we do with her?”

The doctor answered briefly. One of the other attendants then cited the case of another incorrigible patient in some detail, getting appreciative smiles and nodding of heads in agreement with her telling of the story. Stringing together anecdotes about patients was a typical sequence of discussion when a difficult problem came up. Some fifteen to twenty-five percent of the staff discussion on ward E-5 took the form of citing roughly comparable cases.

These discussions occasionally resulted in mutual agreement. The solution arrived at in this way was altogether successful in some cases, less so or not at all in others. The cases where mutual agreement was reached were rare, however. More frequently, the discussion kept getting further and further removed from the problem at hand. The citing of cases went on until the discussion time was exhausted. Since no resolution was reached, the problem was simply abandoned for the time being. If feeling was high, the discussion was resumed in informal session on the ward, and in the next ward meeting. If the topic had become stale, it was simply let “ride” until another incident occurred, forcing resumption of the discussion.

Telling anecdotes about patients did not usually lead to a solution of the problem, but did serve other functions. One of these functions was to relieve frustration built up by staff members over insoluble ward problems. This was done, however, by telling stories in such a way as to maintain existing practices, and to excuse the inability of the staff to act effectively, by putting the onus upon persons other than the ward staff. Thus the patient’s relatives, the hospital administration and others outside the hospital came in for a share of the blame for past failures and mistakes. The chief target in these anecdotes, however, was the patient himself. A survey of some major themes in these stories will indicate the character of the attack.

One major theme of the stories that were told has been mentioned: ridicule. The absurd behavior of a patient can be retold in such a way as to result in laughter, which dispels tension, and, at the same time, tends to discredit the patient in the story, and by association, all patients. In the case above, in which the staff was discussing Rose Ryan, the last story in the sequence of anecdotes broke up the meeting in a burst of laughter: an attendant, by a series of associations, got around to a story of an allegedly promiscuous patient, who was discovered in dubious circumstances with a man on the grounds. The man in this case was a male attendant. According to the attendant telling the story:

I asked the doctor who examined Annette (the patient from E-5) if she had been molested. The doctor said, “Well, your attendant is no longer a virgin.” (General laughter)

The meeting thus ended on a high note, with everyone apparently feeling that something had been accomplished.

A second theme was the dangerous patient. In discussing a combative patient, there was usually a sequence of anecdotes about particular patients who “fought like buzz saws,” “would follow you around, waiting to get you in a corner,” or who “stole a knife and threatened to get even,” and so on, leading to stories which pointed ever more obviously to the danger in dealing with the patients. The staff members in these cases seemed to be saying, in effect, that it is we the staff, who are to be pitied, not the patients.

A third theme was disgust. A problem with the continence or uncleanliness of a patient, which had repulsed all efforts at control, often led to a series of stories about patient behavior which aroused progressively more revulsion. Often, two themes combined. Thus the patient who had slit the throat of her three children in the bathtub was the subject of an anecdote which stressed both disgust and fear. There are other themes in addition, but ridicule, fear, and disgust were the most prominent.

The cumulative result of the constant stream of rationalizations, the labels, ridicule, fictions, and anecdotes, was that an image of the patient was created and maintained in the ward, an image that was congruent with traditional practices. The administration sought to break up this image in its training of the attendants, and in its formal presentations. But the image offered by the administration was vague in outline, and heard infrequently on the back wards.

The circumstance which sealed off the possibility of escape from the ward frame of reference was the condition of the ward patients. The administration programs rested on the assumption that patients were worthy human beings, yet the evidence afforded by the staff’s own eyes seemed to belie the assumption. Most of the patients on E-5 were pitiful in appearance, at best, living under crowded and harrowing conditions. Without adequate clothing and washing conveniences, cut off from support from the outside community, abandoned by their relatives, they presented a sorry picture to staff. Under the impact of the ward rationalizations, the staff was selectively sensitized to only the worst features of the patients, and often overlooked the courage and decency that accompanied these features. In these circumstances, the rationalizations and the administration program seemed Utopian and fanciful.

Goodbye

Copies of the two sides of the farewell card that the E-5 staff gave me on my last day on the ward are below. I believe every staff member is included, as well as the social worker and Dr. Green. Note there are two complaints about Jean Harwood on the first page, since she had ratted on them not once but twice. Beneath the drawing of the car, one person had written: “Harwood, the thorn (in a bed of roses)” and another person wrote next to the complaint, “True.” The reason they loved me is because, as far as they knew, I had kept my mouth shut.

Greeting Card: “Something is Missing: It’s You! Hurry Back”

Thomas J. Scheff is Professor Emeritus, Dept. of Sociology, at the University of California at Santa Barbara. His latest book is What's Love Got to Do with It?: The Emotional World of Popular Songs (Boulder: Paradigm Publishers) 2011

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