Presentation
Introduction
MR. RICHARD LAEL: Thank you for joining us tonight. We’re going to divide the presentation into three parts. I will cover the 19th Century and very early 20th Century. Margo will pick up in the 1940s and Barb will focus on the late 20th Century.
We will, after we speak, have time for comments and questions so please hold those until after we have all spoken and then ask anything you want.
Marmaduke and Creation of the Asylum
In November 1844, two days before he left office, Governor Meredith Marmaduke gave his first and only State of the State address. And according to reports at the time, he was the first state politician to call for the creation of a hospital to assist the mentally ill.
In that address to the legislature, Marmaduke said that the practices currently in use in Missouri, two were unacceptable. One county farmed out the mentally ill to the lowest bidder. Marmaduke said that was simply an inhumane system.
The second method, the counties place the mentally ill in jail. Place them with drunks, with pick-pockets, with thieves, with murderers. And Marmaduke also said that was inhumane.
He emphasized the lack of Christian charity in Missouri. If that is the way we are going to treat the mentally ill, surely as a Christian people, he said, we can do better. And he also argued with the legislature, there is this issue of state pride. He pointed out all the other states that had created a state asylum and what he said, “If they can build them, so could we.”
Well, in 1845, in response to Marmaduke’s request, the legislature debated an asylum bill and they agreed to fund construction. Their criteria in 1845: the site had to be in Jeff City, had to be on 5 to 50 acres of land already owned by the state, because the state didn’t want to spend any money.
Debated in the legislature in 1845, not passed. It was unexpectedly tabled, probably because St. Louis raised a ruckus. They didn’t want the asylum to be in the middle of the state. They wanted it to be in St. Louis. And what you have here is a petition signed by 200 plus people from St. Louis, urging the legislature to reconsider. And that was a battle that occurred in 1846.
When the legislature finally passed an asylum bill in 1847, St. Louis lost. The legislature -- this is a handwritten copy of the bill passed by the legislature. Obviously burned in the Capital fire, this is what’s left.
Criteria for the State Hospital
In that February 17 -- or in the 1847 bill, the legislature said, the criteria are these: The location had to be in one of eight mid-Missouri counties. It needed to be an easy access for people of the state. It had to have a pastoral setting. The assumption at the time is a pastoral rural setting, quiet, bucolic, if you’d like, was necessary for the treatment of patients. This is the -- what is now the rear of the state hospital. You’ll see, if you’ve been to Fulton, down at the very end of the street, the rock barn, which is still in Fulton on Route O. This was a pastoral setting built in the 1880s, Walt’s Greenhouse area to facilitate patient treatment.
Another criteria is the state hospital, wherever it was located in those eight counties, had to have access to nearby farms. The assumption is the state hospital would buy local produce. They didn’t want to haul it long distances, again, because of costs. It needed to be in an agricultural community.
They also said that the agricultural land that the hospital owned or was situated on, 5 to 50 acres, wasn’t enough, which was the proposal back in 1845. It had to be 100 to 500 acres, because the assumption is that patients would labor on the farm and would lower the cost of their care.
Boom Times for Fulton
Fulton won the bidding, and it was a bidding contest. In those eight counties, what the legislature said, who makes the best offer gets the state hospital. Fulton offered $11,500 in cash and 500 acres of land free of charge. It was the best deal the state got. Fulton got the state hospital as a result.
Opens in 1851, but in 1851, Fulton also was the site of the opening of Westminster College and the Missouri School for the Deaf. For Fulton, this is boom times. And you have a lot of stores being built in Fulton. We’re a little ahead, but that’s okay. We’ll get to this architectural. This is Tucker’s Store—right across from the county courthouse that was torn down a couple of years ago—a new store built just down from the asylum to deal with the new business that everyone expected from these three institutions in Fulton.
The first patients arrived in late 1850. The formal opening was in 1851. It was supposed to have opened in 1850, but it wasn’t finished. So it opens in 1851. This is the architectural drawing that was turned in to the state in 1849 before it’s finished. It shows up on every superintendent’s report for several decades. This isn’t how it looked in 1851, but by the end of the century, it was looking better except -- let me back up. By the 1880s, before they totally renovated it and M.F. Bell put a totally new look on it, this is what it was supposed to be like.
First Superintendent Dr. Turner R. H. Smith
The first superintendent was Dr. Turner R.H. Smith of Columbia. Smith was not trained in mental illness, which is no surprise since no medical school taught courses on mental illness in the middle of the 19th Century. Smith had also not practiced with the mentally ill anywhere and that also was not surprising.
In the United States, only one book had been written on mental illness and that had been written in 1812 by Dr. Benjamin Rush, nothing since. You did by doing. You learned by doing.
Smith is the single most important superintendent physician in the state hospital’s first 50 years. He’s going to run the hospital from 1850 to 1861 when it closes down because of the Civil War, resumes running the hospital from 1863 to 1865 and continues in 1872 to 1885.
Smith’s Eight Issues
What I’d like to do for the rest of the presentation is to talk about eight issues Smith faced. Smith’s other successors in the 19th Century—because the problems he faced, keep recurring. They don’t go away.
One: philosophy of treatment. That book written in 1812 by Dr. Benjamin Rush, “Terror acts powerfully on the body,” he wrote, “through the medium of the mind and terror should be employed in the cure of madness.” That’s the only book on mental illness in the nation. Smith, when he becomes superintendent, denounces that concept of therapy. What Smith wrote, and he writes it repeatedly year after year, quote, unquote, “Violent hands shall never be laid on a patient under any provocation.” Big contrast.
In 1868, newly appointed superintendent, Charles Hughes, who would run the hospital until 1872 and who replaced a superintendent who served briefly from ’65 to ’68 by the name of Rufus Abbott.
Superintendent Hughes remarked that his goal running the hospital, unlike his predecessor Abbott, was to use persuasion not coercion, kindness not violence. And, yet, Hughes later said,”Creating uneasiness and pain in a patient could divert his or her attention from their delusion and could rouse the system and, therefore, should be done.” So coercion comes back. Pain comes back.
Second issue that is going to recur: use of restraints. This is an example of a restraint made to sort of look like the clothes they wore, not scary. Although undergoing change at the time, many eastern U.S. hospitals by the middle of the century still liberally used restraints. But Smith, when he opened the hospital and ran it, rejected such liberal use. His view is freedom of movement was a desirable approach unless absolutely essential to protect the patient or other patients in the hospital.
By 1868, Superintendent Charles Hughes was more liberal than Smith in his use of restraints, especially on female patients. Hughes argued females especially needed to be restrained because the timidity of female attendants often need -- meant they could not handle the female patients. So at Fulton, under Hughes at least, women tended to be restrained, men did not.
Three: use of drugs. Smith denounced the practice in many eastern U.S. asylums where drugs were heavily used to sedate the patient. He disagreed with that. Rejected a blanket use of drugs, argued that each patient needed specific care, and you use drugs only when absolutely necessary and never as a blanket policy toward the whole asylum.
Superintendent Hughes in the 1860s and ‘70s rejected Smith’s approach. He liked the approach going on in the eastern part of the United States, quote, unquote, “I would part with any other remedy,” Hughes wrote, “before I would give up Opium. Use of drugs,” he says, “blurs patients’ misery and diverts them from their delusions. If I don’t have Opium, alcohol will equally serve.”
This debate over the heavy reliance on drugs is going to be one of the most controversial issues in the late 19th Century at Fulton.
Four: use of attendants, the original name for nurses. Smith argues that nurses, or attendants, were critical partners in treating the mentally ill maybe because initially he was the only doctor.
Hughes, his successor, agreed attendants were critical, but by the end of the 19th Century, Fulton superintendents did not believe that was the case. By the end of the 19th Century, they were concerned not with the training of the nursing staff, just that they had enough numbers to keep people quiet. But this issue of partnership between nurses and doctors disappeared virtually by the end of the 19th Century.
Five: use of work as therapy. Smith firmly believed in 1851, and he never changed his mind, patients were better served by working. But Smith believed it needed to be voluntary. You couldn’t coerce the patients to work.
Superintendent Hughes, in the 1860s and the 1870s, said it wasn’t the patients’ choice. They would work, and if they didn’t want to, he would force them to work. A different philosophy, but work was seen to be important in the curing process for the patient.
You see various slides here. This is the sewing room of the hospital. The next slide, I think, is going to be a ledger. This is a ledger where the hospital kept detailed records of what patients produced. This comes out of the sewing room. This is a garment book. It was kept from 1937 to 1970. So this is a process. This working at the asylum was an important process throughout the hospital’s history until most recently.
Six: adopting a more scientific approach to terminology and treatments. Smith argued in 1851, there was no common terminology used by physicians when describing mental illness. So if he were lucky enough to get a patient history and he would read it, he didn’t know what it meant. And that was the problem. There is no common terminology in the middle of the 19th Century.
By the end of the 19th Century, that’s beginning to change, but until then, the causes of mental illness were frequently listed as disappointed love, jealousy, religious anxiety, intense study, intense work, domestic trouble, masturbation.
Medical terms to the medical community today that might be more familiar only began to emerge at the end of the 19th Century replacing these other causes.
Seven: likelihood of cure. When the legislature was told that we needed an asylum in this state, they were talking about a 90 percent cure rate, if they could get patients within the first year. Legislature built the asylum. Within three years, they were talking about an 80 percent cure rate. By 1854, the hospital had to report to the legislature they’ve only cured 23 percent. By the end of the 19th Century, by 1888, for example, the cure rate was 13 percent. By 1900, the hospital had become basically a custodial institution. There wasn’t the emphasis on cure. It was keep.
Eight: lack of money. Lack of funds throughout the first 50 years was a constant problem. Repeatedly legislators were asked to deal with overcrowding. This is an example of the crowding of the beds in the 20th Century.
Renovations would occur because of the state legislature. The M.F. Bell renovation, which changed radically the profile and raised the roof, literally, so you added another floor to the hospital. The Bell renovation in the middle of the 1880s -- within three years, Fulton was 35 percent over capacity. It was a common problem throughout the 19th Century and in to the 20th Century.
Lack of funds also meant abysmal fire protection. There was an inspection at the hospital in the 1890s, and the inspectors reported there was one fire hose cart, like this, for the whole hospital, and it was so deeply buried in one of the sheds that they couldn’t get to it. And that was it. There was no other fire protection. It is a constant problem facing the hospital.
Lack of funds meant too few staff to deal with too many patients. And lack of funds also prevented superintendents from doing what they argued they should do from the 1850s throughout the 19th and the first three decades of the 20th Century. We need to separate the criminally insane from the regular insane, but the legislature didn’t until the 1930s appropriate the money to do that.
But lack of funds did not prevent the hospital from segregating based on race. African Americans were segregated and remained segregated until well into the 20th Century. We could afford to do that. They simply stuck the African American patients in the basements and in the worst buildings on the campus.
Many of these issues faced by superintendent physicians in the 19th and early 20th Centuries are still with us; lack of funding, too few staff to deal with too many patients.
Margot will continue with the 1940s.
The Community and the Asylum
MS. MARGOT FORD McMILLEN: Thank you, Butch. We really appreciate all of you being here. And I am going to continue with the 1940s and talk about the -- more about the social perceptions of the asylum and the residents of the asylum.
In Fulton, the community has a very -- still has a very intimate relationship with the asylum or with the hospital -- as we call it now, the state hospital.
And in the 1940s, that was certainly true. It was Fulton’s largest employer. It was very active, if there was some kind of community event, like a Christmas parade. The hospital people -- almost everybody had a family member or neighbor that worked at the hospital or generally a family member. And really the staff was very trusted, so that the community used the doctors at the hospital as their own doctors.
The county didn’t have its own morgue. They used the state hospital morgue. The dining room was even a popular place to go and eat sometimes. Families would go on Sundays to eat at the state hospital.
And it was real common to see the state hospital, because it was -- they owned so much land by the 1940s that it was really part of the rural landscape.
Over on the little corner there, you can see that there is a playbill and that was something that people would go and see the plays that there were at the hospital that the patients would put on.
Resident Stories
But, you know, we’ve lost a lot of the patient stories -- the resident stories because of patient privacy, and I think that this is something that we really try to recover in writing the book. The earliest story that we found was the story of Eliza Bingham. And she was the second wife of the artist and politician George Caleb Bingham. And her story and the other stories that we found kind of make us realize that while people were hidden away because of their mental illness, society was still interested in them.
And I’m just going to give you a little quote about Eliza and the trip that she and her husband took to Fulton when she was moved to Fulton. This was out of the Moberly newspaper, and it says, and I’m quoting, “The two passed through Moberly on the railway. One of the saddest spectacles our reporter ever witnessed. For many a weary year have this twain traveled life’s wearied journey hand-in-hand and the aged partner of the painter-statesman had cheered him in adversity and rejoiced with him over his triumphs, but suddenly as if the sun were stricken from the heaven at noonday, the light of his life went out and the partner of his joys and his toils became a hopeless lunatic.” And, you know, I think that’s kind of a tender little tribute to her. And the article says that the two of them were accompanied on the trip by quite a party of friends. So there was some sympathy from the community for their plight.
The Modern Age
There’s a lot of stories about society’s perception of the hospital and of asylums in particular. One of which we’re going to talk about that really happened in the 1940s. But let me give you a little bit of -- we can change the slide -- of what was going on in the 1940s at the hospital.
You can see on the left -- this is the new medical building that opened at the state hospital, and that medical building was equipped with the latest technology. This was in 1940. And it had things that were just dreamed of beforehand and things like this odd contraption that looks like a steam bath, that was to soothe people who were in turmoil. Lots of equipment like that.
It also had just regular medical doctors working so that -- because there was a lot of curiosity and wonder. Gee, maybe a lot of these diseases are caused by something very simple, some liver ailment or something like that, that’s destroying the chemical balance of the body. So they were given medical treatments and trying to work through all this.
In the 1940s, the patient census was pretty high, 2,476 people, which was definitely, like Butch told you, over capacity. But there was a new Biggs Building that had been finished for the criminal insane. There was a building that provided an auditorium, a kitchen and a cafeteria. And these rural scenes were pretty typical of what you might see if you were in Fulton.
There’s a hog pasture up in the top and barn down here in the corner. This is the kind of thing that a Fulton resident would be real companied -- you know, real familiar with. The patients were either unpaid or they just earned a few dollars and they worked in all of the kitchens. They worked in the power plant. This is a picture of the new power plant and you can see that -- I think it’s kind of interesting, maybe not that unusual, but they ran all of those new electric wires through the old tunnels. So that insert there shows you that those tunnels that had been built for -- just for communication between buildings actually served a great purpose, carrying the steam pipes and the power to all of the parts of the hospital.
But there wasn’t really any kind of money for staff training and so the patient treatment was very primitive. One of the nurses told us that for controlling violent patients, she was equipped with a towel and a sock with a bar of soap in the toe. And the staff could wrap the towel around a patient’s neck and just twist it until the patient passed out or the soap could be swung at a patient’s head and knock them out.
The End of Patronage
So this lack of training was obviously a huge problem to be addressed. Missouri was nearly four million dollars in debt at the time and it was right at the end of the Depression. So Governor Forrest Donnell really wasn’t able to expand the budget, but he was able to end the patronage system. And that was the system that said that government jobs were awarded according to political power. If your power -- if your party was in charge, you might get a job, but it didn’t have anything to do with your expertise or abilities in working with people.
So Donnell pledged to change that system, and there was actually a new constitution written to end patronage. And I told somebody how great the webpage is for the Missouri State Archives. They even have this bill that ended patronage on their website. And so thank you to them for that.
Kings Row
You know -- and so what happened is there had to be a new constitution and there had to be a new set of laws written. And this really got people talking about mental health and about the state hospital, but then something happened that really jump started the whole discussion. And that was the publication of a book in the spring of 1940. The book was called -- or still is called Kings Row. And I wonder if any of you have read that book. Has anybody read it?
Oh, great. A lot of people have read it. Well, it was in the top ten of the bestsellers list for months, and Fulton residents knew who most of the characters were. It was written by one of Fulton’s native sons, Henry Bellamann. They could -- if you talked to somebody from Fulton, they could give you details about the incidents in it. One of his -- Henry Bellamann’s sister, who was still living in Fulton, told the St. Louis Post Dispatch, this is a quote, “One-half of the town is angry because they think they see themselves in Kings Row, while the other half is angry because they were left out.”
Professor Jay Carr from Westminster did a map, and he took the map of Fulton, which is basically this map here, and wrote down the places that are in the book and how they were actually places in Fulton. So it’s kind of an interesting thing. But it’s -- you know, you might want to just sort of pass that off as something interesting and quirky about our town. But in a larger sense, Kings Row was really the first in a new genre of books and movies. And it was made into a movie in 1942, and maybe a lot of you saw that movie with Ronald Reagan in it.
This genre really grabbed the public’s attention and if you kind of start looking at these -- I really -- if you’re interested in this subject, it is fascinating to just borrow these DVDs and videos and see all these films that were made at this same period of time.
Spellbound
Alfred Hitchcock produced Spellbound, which was a psychological thriller. It started with a written prologue that kind of scrolls across the screen and it says, “Once the complexes that have been disturbing the patient are uncovered and interpreted, the illness and confusion disappear and the devils of unreason are driven from the human soul.” And so there was this kind of hopeful ending, and all these films shared this, that, you know, even though things were really terrible for the patient, that there were techniques that could free them from this torment. Spellbound -- I’ll just mention that psycho -- that Ingrid Bergman played a psychoanalyst. It’s -- I’m telling you this is a really fun movie to watch.
Gregory Peck was the accused murderer in the movie, and Ingrid Bergman says, “Open your mind and the pain will leave.” And she does dream analysis. And the dream sequence was designed by Salvador Dali. So, I mean, it just gets all of the top folks in that movie. But actually that movie didn’t win any Oscars, because the same year, another film called the Lost Weekend, which was about alcoholism, appeared. And it was -- starring actor Ray Milland and it actually gave, you know, the idea that there was a very vivid and accessible cure to alcoholism.
Snake Pit
Finally, in 1948, there was another one called Snake Pit, and that was actually a much more realistic film. And it actually -- a quote from Snake Pit kind of entered the genre of all of mental health writing, even in Missouri, when the state legislature had to do a study of the Mental Health Department over here. They used this quote and they said, we haven’t got enough of anything but patients.
And that’s kind of what was happening with them. I mean, they didn’t have enough money. They didn’t have enough expertise, but they certainly had enough patients.
One Flew Over the Cuckoo’s Nest
Well, if you follow this -- and I imagine a lot of you have read some of these books and seen some of these. You probably know that all of this attention led to a book in 1962 called One Flew Over the Cuckoo’s Nest. And, again, we have sort of art and life imitating each other.
Civil Rights
In the 1960s, in Fulton and everywhere else, there was a lot of attention given to Civil Rights. And on the left here you have our first black physician at Fulton, and that was Dr. Elmer Jackson. And he actually lived in Jefferson City, so some of you may have known him. He was hired in 1960, and he served in just about every department at the hospital and retired in 1989. And he was very -- we had another really able administrator who worked on Civil Rights and lots of other things, Dr. Donald Peterson. And we couldn’t really talk about the ‘60s without mentioning Dr. Peterson, because he was very important to it.
Patients’ Rights Movement
But the kind of attention on Civil Rights and the books by [Ken] Keysey and other thinking that was going on at that time led to another movement that really affected life in Fulton. And that was the Patients’ Rights Movement. And some of you might know a little bit about that. It kind of ended -- Barb’s going to talk more about this, but it kind of ended with the idea that patients could not be held within the asylum against their will. And what that led to was the end of patient labor, which Butch talked about, and really the end of the self-sufficiency of the state hospital.
The dairy was sold and the gardens were turned into ball fields for the City of Fulton, because these things really depended on unpaid patient labor.
So I am going to pass the baton to Barbara and let her pick up the story from the insider’s point of view as someone who has worked at the hospital.
An Insider’s View
MS. BARBARA BRAZOS: My name is Barb. And I worked at the hospital as an LPN. I started in 1983. And I actually never saw any of these chairs, but they kind of give you the idea about the massive number of patients and what their lives must have been like, how regimented and empty.
1950s Statistics
In the 1949-1950 official manual, it was reported that the patient population was 2,565 with a capacity of 2,677, and actually at that time there was 112 extra beds. The cost per day for keeping a patient was $1.65. I think it’s over $500 now.
Patients were served by 530 employees whose salaries ranged from $1,200 for custodial workers and $7,872 for Dr. Kramer, the superintendent’s salary. The largest category were the Hospital Aide 1. They made $1,380 annually, and they worked 12-hour shifts. And they worked seven days and then had one rotating day off. Benefits included housing on the campus and medical care provided by the state hospital doctors. I think people that worked there were not too trusting of the town doctors, but you and your family could have surgery there. You could get your kids’ tonsils out -- appendectomies and it was kind of a different place. I think everybody had the feeling that the patients were being taken care of and the staff was, too.
And I always like these light bulbs. A lot of the early pictures just have a bare light bulb in the ceiling. And I don’t know what happened to all those chairs, but I think this is just a glimmer of new things that were going to happen.
Thorazine
In 1954, Thorazine went on the market. And it was the first medication that really treated psychosis, and it was called -- in a new class of medication, it was called a neuroleptic and that meant it kind of grabbed your nervous system. It created what they called an artificial hibernation, and it was marketed using similar marketing strategies that the pharmaceutical companies use today.
Thorazine sponsored television programs. There was full page ads in all the medical journals to educate doctors about Thorazine. And within eight months, it had been administered to two million psychiatric patients. And Thorazine was effective for reducing the level of violence in institutions.
I always wondered about these chairs and how people were, perhaps, restrained in them. And I’m thinking that might work. If patients could rock back and forth, maybe they wouldn’t get decubitus ulcers. And I’m thinking those might be too heavy for an agitated patient to turn over.
The Canteen
You can go to the next slide. This is a picture -- it kind of tells about -- it’s a little bit later, but it tells about how the hospital was trying to find something that was a little more normal, that they wanted to avoid the concept of having institutionalized patients in caretaking, and so this lady is getting her hair done. And they started the canteen in 1940, and that gave some patients a different kind of job. The proceeds from the canteen were spent on theater events, on trips, movies, ball games and parties. And they had a barber shop and a beauty shop. And so -- although many patients spent their whole lives there, it did seem a little more -- less institutionalized.
Employee Education
We can go to the next slide. There were no registered nurses working at the hospital in 1953. Employee education was started by a practical nurse, Doris Brown, and she spoke with Dr. Kramer. She saw the need, because she said that the new employees just started to work and they had no prior experience or formal training in patient care. So she wanted to teach them how to do vital signs and make beds before they started working on the wards.
In 1950, the shifts were 10-hour shifts, and hospital attendants were administering medication. One person told me about how she had worked there three nights and she was expected to learn how to give these meds and read these charts, because she was going to be doing it on her own. And when she protested, her only option was to quit. And her mom was kind of mad at her and said, Well, that was a good ward. And Thorazine, she said, came in gallon jugs. And they administered a lot of it. In fact, I think they administered some of it in Kool-Aid just that sat out on the tables.
By 1972, employee education was greatly expanded and actually lasted formally for six months. Patients -- staff worked on the wards and then they had weekly classes in anatomy, physiology, medications, psychology and patient interactions. And staff shortages were always and still are an ever present problem.
One person told me that when she started back to work there, she said there was evening interviews. And she said that she went to the evening interview and they hired everybody that showed up. And then they gave them a bus ride around the campus and that was like their first orientation. And that was about 1972, and I think they were trying to get ready for a JCAH [Joint Commissions on Accreditation of Hospitals] inspection, which they actually failed. In fact, they failed two of them. And they lost millions of dollars in state funding -- I mean, in federal funding. And at one point in 1974, employees were voting on if they would agree to work without pay for three days to make up for a short fall in the hospital budget and save other employees jobs.
In 1978, the pay raises given by the state, they classified psych aides as non-skilled labor and they got the minimum amount of salary.
New Chairs
These are the new chairs. This is the next evolution in chairs. They got a new version that’s a much lighter chair. I think with Thorazine, a lot of patients had akathisia. They had kind of a restless leg feeling. And the tardive dyskinesia causes repetitive movements in the face or trunk. And I think a lot of patients were still just rocking in rocking chairs. That was about the extent of therapy. These chairs were around for another 20 years. In fact, I think they wore grooves in the sidewalks. They were inside and outside chairs. And I think you can still see some of them in Fulton. People have them in their backyards.
And patients just sat and smoked cigarettes. It was a while --
MALE SPEAKER: Could you get closer to the microphone, please?
MS. BARBARA BRAZOS: Pardon?
MALE SPEAKER: Could you get closer --
MS. BARBARA BRAZOS: Oh, I’m sorry. Yeah.
There was -- it was awhile before they had any other kind of occupational therapy, recreational therapy or any of those kind of amenities. The canteen was started in 1940 -- oh, I already talked about that.
An Extension of Home
Let me see. Someone told me that working at the hospital was an extension of home. And patients and families, they were kind of like family. You saw the same patients every day. Hardly anything changed for them. And their own families had been alienated by, perhaps, their symptoms of mental illness. And there was a tremendous -- this is -- they’re packing Christmas boxes for the patients. They -- individuals and groups donated and volunteered from the immediate community and beyond and they provided all kinds of activities and gifts for the patients. There was art and education, entertainment, socialization events, Christmas parties, like this, and fraternities and sororities came and caroled. There were people that adopted wards and remembered patients’ birthdays. And there were Friday night dances that were, at one time, attended by the town people.
In 1960, the Mental Health News reported 2,500 visitors to the state hospital from 73 towns. That was during mental health week. And the Ozark Opry played at the carnival that year in June.
I think this next slide is of an Easter party, and it shows you those chairs. We had a whole fleet of them. This loom was probably sold at a state surplus sale, because I know someone that has one. That would have been part of an occupational therapy program where they made a lot of ceramics and household objects and some rag rugs that were really nice and they were for sale to the community.
Eckerhart vs. Hensley
I think a lot changed with the litigation that Margo mentioned. In April 1972, Eckerhart vs. Hensley was a lawsuit claiming, quote, “Inadequacy of care and treatment.” And that was filed by the St. Louis Legal Aid Society. Count 1 condemned the treatment and conditions at Biggs. Count 2 challenged patient placement without due process. And Count 3 sought compensation for patient labor. There was also something about voting there and that was -- that part was settled pretty quickly, but it was another year before Judge Elmo Hunter ruled that patients could not be transferred to Biggs without a hearing, that patients in Biggs were entitled to an immediate review of their treatment plans, and if patients met their goals, they must be transferred to a less restrictive environment within 10 days.
If these conditions weren’t met, the superintendent and the Governor himself would be in contempt of court. It was also decreed that the hospital needed to provide for the religious expression of black Muslims and that patients could convert to any religion without interference.
The federal district judge, Elmo Hunter, said that also at the trial that they needed two more psychiatrists, five or six social workers, three or four psychologists and five or six clericals. The department had already requested 36 new employees for Fulton. He also said that it was -- he didn’t rule on it, but he said the environment was drab and depressing and that in itself could be harmful or counter-therapeutic to patients who may become withdrawn as a reaction to their environment. He also noted that additional money for staff, quote, “is highly desirable and would be the act of an enlightened legislature.”
Work Programs
They -- the patients could no longer work and their work ceased abruptly. One day they were going to their jobs and had been for a long time, and the next day they were just sitting on their wards with nothing to do. And I think that a lot of people told me how sad and demoralized that was for them, that they had been making contributions and now they weren’t. A lot of them were seriously depressed, and I think after a lot of thought, things were revised. There are work programs -- there were work programs, but they had to be compensated at a fair market value. And eventually it became recognized as part of their therapy, incorporated in their treatment plans and the Brant Vocational Enterprises provided piece work. There was like -- they had a real job to do.
At that time, I think Biggs was in terrible turmoil about how they were going to evaluate all those patients and get them moved across the street.
Children’s Ward
This is a view inside the oldest wards, the old south ward that was not destroyed in the fire in 1956, and you can see how very crowded it may have been and why JCAH didn’t accredit the hospital. They built a new geriatric building in 1961, and a new administration was built in 1958. The children’s ward was actually housed in this building. This I believe is a children’s room and it’s luxurious because it is a private room. It’s pretty austere but you can see that they have accumulated some trinkets. It was not air conditioned. And I just think that it is kind of ironical that this pre-Civil War building was part of this new patient population.
At one time, there were over 100 children at Fulton and they were a diverse group. And I think basically they amounted to an overflow from foster care. There was a paid grandparents volunteer program and a lot of activities. Their education was there at the hospital and it also included a mechanic shop for vocational training. And they had a state-of-the-art television studio where they made videos, kind of educational videos for the Department of Mental Health. And I don’t know, they recorded a lot of stuff there.
Outpatient Clinic
This is the outpatient clinic. In the ‘40s, they had insulin shock. They had ECT where they – electro-shock where they would -- and they gave that out indiscriminately. There was a lot of shocking going on. Patients arrived one night and they were on the list to go to ECT the next morning. And with medication -- with Haldol in the ‘80s and long-acting drugs, there was another possibility that occurred that, perhaps, a lot of these people could leave, that they could go to nursing homes or group homes or some kind of supported community living.
And Clozaril in the late ‘80s is still the gold standard for psychosis, but it was rarely used because of the risk of serious side effects and because of the expense. When it came out, the state budgeted for six patients to get Clozaril and part of the criteria was primarily based on how much family support they had. If they did improve with this medication, was there a place for them to go? Would their families be interested in having them at home again?
Gradually patients were discharged. They came back for their monthly shots. And the hospital building that at one time had its own ICU and surgery was dedicated to office space for case management and wraparound services for the Fulton 59, the very last patients that were not forensic to leave the hospital. They had extra money that followed them to make sure that they could do well.
Recidivism
This eliminated the problem of warehousing patients that would never be released, but it also created a new problem recidivism that patients were in the hospital for a shorter time. But then they went out, got off their medication, got in trouble, and here they were again. Readmissions were expensive and there was something about the home counties refuse to pay for their patients. I guess they were expected to contribute something and the counties felt -- their rationale is that the state should pay for everything.
On January 1, 1980, outstanding county bills amounted to $1,634,000 and, of course, when JCAH didn’t certify them, they lost their Medicare and Medicaid certification.
Social Learning Program
Another new treatment was the social learning program that came in the early ‘80s, and that was a new kind of treatment. It was about re-educating patients so that they weren’t institutionalized, so that they could interact, so that they could budget, so that they could be aware of themselves and the people around them, so they could participate, and they received tokens for their participation if it was appropriate. And they had to do appearance checks. They had to keep their shirts tucked in. They had to be neat and clean. Their hair had to be combed. And it was successful. There was a lot of questions about it, because some people said that it had been successful because they hand picked the patients and they hand picked the staff. It was the very best staff and probably the most likely to succeed patients.
And then a patient who was at the hospital in the social learning program died. And I think that there was some question about the future of the social learning program. This -- there still is a social learning program and they’ve also included other programs. Cognitive behavioral therapy, which is just kind of about thinking things -- about how you’re going to react before you do it impulsively. Social learning was a very new concept and it was very innovative for Fulton to have that. It was also adopted by St. Louis Hospital and it was used in Texas and Tennessee after that.
In 1991, they closed the Hearnes Center, which is where all the children were housed, and they sold their farms. And this is a carnival.
The Harvest Festival
Dr. Baur in 1954 started the carnivals and those continue in kind of a reduced form. Now it’s called the Harvest Festival. But at one time, they got a little carnival to come to the parking lot and there was unlimited cotton candy. Patients and their families would come, and staff. And anybody could ride the rides all day long and there was a balloon toss and turtle race games. And I think at one time they were two days long.
There’s the merry-go-round. This is the Biggs Chapel. One of the other things Dr. Baur did was start the chaplains program in 1956. I don’t think you can see it very well in this slide, but I was really intrigued with it, because there is a little strand of barbed wire at the top of this picture. The chapel has a changeable iconography to accommodate various space. You can just put one thing and get the other thing out. And the chaplains traveled to Mid-MO and do ecumenical spiritual groups weekly. There are several stained-glass windows, but that one was particularly pretty.
Future of the Hospital
And about the future of the hospital, I think you should know that Fulton State Hospital is all forensic now. All the patients there are either NGRI, not guilty by reason of insanity, or their competency to proceed is being assessed or they’re trying to be treated so that they will be competent to proceed. And all those patients have a severe mental illness and a serious legal charge.
I think that the next phase of the de-institutionalization is privatization. That’s what the Department of Mental Health is talking about now, is someway to privatize all the non-forensic state hospitals such as Mid-MO and Metro-Psych and Western-MO, and I think we’re teetering on the brink of another new age.
I really can’t tell you how it will look after they privatize, if they do. But right now they still have the same problems, and I don’t know how privatization is going to fix it. Right now in Biggs, there is a 43 percent vacancy in RN positions. And -- well, orientation is four weeks now and the aides are CPR Certified and there is also PART [Professional Assault Crisis Training] training, which is supposed to educate staff about how to de-escalate the violence before it gets out of hand. But I think that restraint seclusion is a daily event in Biggs.
So I think what I learned from all this is that sometimes when you, you know, change things, it’s going to be really hard to get it back. So I’m kind of concerned about the future of the Department of Mental Health and what it might look like.
MR. RICHARD LAEL: Thank you for joining us tonight. We appreciate it.