Institutional Peonage: Our Exploitation of Mental Patients

As A resident in psychiatry on the staff of a state hospital, I used four men to assist me in giving electric shock treatments. In contrast with the disharmony of the treatments, the men moved smoothly and effectively. They would escort the patients individually to the treatment area, reassure them, efficiently hold them during the seizures, and then watch over them in the recovery stage. These four men themselves were patients and had been for a long time. And as time went on they proved to be even more useful and made a real contribution to the ward life.

For example, the night shift in that building of four hundred and fifty patients had only seven women attendants. Before the advent of drug restraints, it was the custom for the preceding shift of attendants and these seven women to put ten or more patients considered potentially troublesome into seclusion rooms for the balance of the night. As this solution was in response to the lack of male attendants, I organized my four assistants into a team to be on call twenty-four hours a day to help, as required, in handling patients.

This innovation was greeted with some skepticism by both the attendants and the patients, but actually worked out very well, and the seclusionroom census fell promptly from ten or more a day to one or two patients a week.

Ostensibly in the interest of esprit de corps, the four men were given armbands designating each as a “First Aider.” Two unused rooms were fitted out with beds, chairs, and bureaus for their use, and for a time they each received a token gratuity of a fifty-cent canteen card per week. Although this arrangement with the First Aiders was not patently on a quid pro quo basis, it did constitute symbolic payment for performing their seven-day-a-week d uties.

Only after I was away from the state mental hospital for a while, however, and could view my use of the First Aiders in some perspective did I come to realize that this really represented a gross abdication of my primary responsibility as a psychiatrist. The recompenses I arranged for the First Aiders may very well have led them to consider me a good guy. But as an integral part of the hospital, whose interests came first, I was actually being a very poor doctor to them: they were helping me with masses of other patients while their need for recovery and discharge was completely overlooked. Their role of institutional worker was so established and self-effacing and accepted that the question of their further recovery never came up.

In all of the large state hospitals, patients who are needed to be used as unpaid laborers are so used. The extent to which patients perforin labor in state mental hospitals may surprise their families and friends. Every hospital uses up to 75 percent of its men and women patients as workers in the institution and about the grounds. Patients work on the farm, in the dairy, on the grounds, in carpenter shops, kitchen, dining rooms, and laundry, and in the wards, as well as in maintenance and engineering.

Unfortunately, this exploitation can be accommodating to their illness and increase their dependency on the institution. Rather than getting well, they can become “good patients,”and their hospital stays stretch into years. Tragically, without such institutional peonage on the part of its patients, the state mental hospital system would have to close down completely.

Similarly, in England Dr. J. A. R. Bickford, an English hospital physician-superintendent, with refreshing bluntness, voiced this opinion in the March 30, 1963, issue of Lancet: “The economy of a mental hospital is based on ‘patient-labour’. . . . That patients should do a little domestic work, to foster a feeling of community and to teach them how to care for their homes, is reasonable. What is unreasonable is the extent to which the hospital is dependent on their work. In fact, without it the hospital could not run and the mental-hospital service would collapse. . . . Nobody pretends that most of the work patients do is to their advantage. It is dull, negative and without therapeutic value.”

The labor needs of the typical state mental hospital are admittedly substantial. Typically, it must exist in isolation from other social institutions, providing as best it can for all the needs of its patient population out of its own internal activities and resources. In the aggregate, the requirements include furnishing and maintaining usual community service needs of town-sized proportions. These can be staggering.

The minimum needs are, nevertheless, supplied at a national median outlay of under $6.00 per patient per day — a depressingly low figure when compared with the $37.50 average daily cost of voluntary short-term medical hospitals (without doctors’ salaries). This covers direct cash outlays by the state for salaries of all professional groups, attendant staff, maintenance and service personnel, as well as contracted services, medical supplies, expendable supplies and equipment, food, fuel, utilities, tools, clothing, vehicles, and whatever else is required. However, as only a very few patients are paid the most modest gratuities, and then in only seven states, the value of the labor of the working patient is not reflected in the above cost. Obviously, the working patient carries the hospital on his back and subsidizes its functioning.

In other words, state hospitals need “good patients” who are useful, valuable, and expediently indispensable. But these relatively less ill patients, instead of being helped to overcome their illness, as is normally expected on behalf of the patients in any other medical care facility, are doomed by the institutional needs of the state mental hospital to the pathological dependency characteristic of “good patients.”

Obviously, rather dreadful exploitation can develop. For example, on virtually all back wards, where listless, overactive, incontinent, or incapacitated patients are kept, there exists a cadre of working patients who, to the casual visitor, are indistinguishable from the others. These patients do most of the ward work under the supervision of the attendants. In return they receive certain privileges and rewards and determinedly protect their status by not attracting attention to themselves. The most distasteful example I know of was a patient-worker on an incontinent male ward, where he did much of the bed changing, cleaning of the old men, and such. He was a diligent worker who in reality, I eventually discovered, was a homosexual taking care of his harem.

When I called this startling situation to the attention of the superintendent, he agreed that it was deplorable. “When you find somebody else to do his work,” he said, “let me know, and I’ll have him transferred.”

Dr. Ivan Belknap, the sociologist, noting workers on back wards, admonished: “the effects of living with deteriorated patients are obviously not those desired by modern psychiatry for treatment of the patients who are closer to normality and capable of maintaining good contact with reality. And it is also evidently not a desirable professional situation when the physician in charge must go along with the requirements of ward management and housekeeping without primary reference to desirable courses of therapy for patients.”

THE use of a patient as a worker in a mental institution could perhaps be justified if it could be demonstrated that such work is voluntary, that it is paid for at prevailing wage rates, or, above all, that it contributes to the effective treatment of his illness. Unfortunately, none of these conditions prevails. Patients become institutional workers if the work and the implicit symbolic payment gratify their dependency needs enough to make them useful and immobilize them. The nonworking patient, unable to mobilize himself and hopefully kept inert, repeats his pre-institutional role of failure, this time in the still more destructive role of a public charge. This process is regressive for both groups: formerly skilled persons can become satisfied dishwashers: patients on the wards who are not working and who could benefit from learning to wash dishes are denied this opportunity.

The work performed by state mental hospital patients is often described as voluntary. However, when such a patient “volunteers” for work that is by any standard degrading or boring, he is in reality surrendering to the compulsions of his institutional environment. Defenders of the system claim the patients “would rather work than sit on their hands all day,” and this is true of those who are chosen to work and acquiesce. Yet patients who respond otherwise — the hostile, combative, and uncooperative individual on the disturbed ward and the listless, unresponsive one who, in effect, do sit on their hands — may be viewed as more prideful human beings than their leaf-raking colleagues of many years.

As non working patients spend virtually all their time on their wards, and working patients a greater part of their time, familiarity with the ward environment can be illuminating. State hospital “continued treatment" or chronic wards are the most poverty-stricken environments imaginable. The brindled drabness, the bare furnishings, the expanses of tile, the absence of private areas (even in the bathrooms) make the poverty all-encompassing. It eliminates all the stimulation of personal identity: no bedspreads, no pictures or a place to put them, and no individual possessions — books, trumpets, tennis rackets, or hobbies. It is this lack of stimulation, of course, which becomes the ward’s greatest triumph: the patients look around, see how they are assigned, and end up looking and acting all alike.

Those areas where the treatable or privileged (more amenable?) patients are to be found are those most commonly pointed out to visitors — canteen, occupational therapy areas, the current pilot (or research) treatment area, the open convalescent wards, and the athletic facilities. These are the places where volunteers flourish and in which the staff takes pride. The back wards, regardless of their human needs, repel.

Recently I arranged for a lawyer and two residents in psychiatry to be shown through Norristown State Hospital by a staff member. Much to my personal dissatisfaction, the suggestion to see the more dismal wards was promptly rejected by my three visitors (the purpose of the visit, to my mind). And the most time was spent in the newest building. It was a privileged building, reserved for working men patients, who were all out working!

Obviously, the patient who volunteers for dirty, degrading, or boring labor in a state mental hospital does so not in the sense of offering his services freely and willingly but as a means of getting away from his assigned ward — which, indeed, is part of his symbolic payment.

These considerations were not appreciated in the American Bar Foundation’s 1961 study, The Mentally Disabled and the Law, which was innocently taken in by the Council of State Government’s misinterpretation of its own questionnaire. The council study reported — and the lawyers passed on the information that “one-third of all state hospitals pay their patients for work,”although the word used in the council questionnaire was “compensated,” not “pay.” Actually, the one third of the hospitals which reported compensating patients were referring to symbolic payment, which the other hospitals did not report as compensation.

Furthermore, the study revealed that most states do not have statutory provisions governing the employment and compensation of patients. Even where covered by statute, “it is unclear whether the purpose of statutes authorizing patient labor is to provide occupational and vocational therapy for the patients, as appears to be the case in Pennsylvania, or whether it is to provide free labor for the institution, which might be the case in Iowa.”

However, in Pennsylvania some light was recently cast on the subject by an assistant attorney general. He addressed himself to a query in regard to fulltime working patients who were virtual employees, to the extent of living and eating in dormitories with paid employees and having freedom to go to town when not working. Payment or reduction in their per diem bill be found unwarranted, as “it would not be satisfactory to attempt any anomalous relationship [involving formal compensation] which would in a legal sense detract from the patient status of the inmates.”

THE state hospital medical role has primarily served to justify and legitimize the state hospital and make it safe for the community. The nineteenth-century doctor-superintendent, in the absence of medical treatment, personified “moral humanitarianism,” which was then the ideal of treatment. Subsequently, as the custodial nature of the burgeoning state hospitals developed, as pessimism in regard to mental illness resulted, and as office-oriented psychiatry blossomed and nourished, the state hospital medical staff became more and more isolated geographically, socially, medically, psychiatrically, and now linguistically. To cite one recent example, all of South Dakota’s hospital staff doctors were foreign-born and had language difficulties.

As all but two states issue restricted medical licenses or temporary certificates for their state hospital physicians, it is apparent that medical standards unacceptable outside the hospitals are tolerated within. This means that foreign doctors of questionable training and ability and Americanborn-and-trained doctors with serious personality and other deficiencies not only are sought after, but their presence repels the adequate and the licensed. Reasonably enough, Greer Williams, director of information for the Joint Commission on Mental Illness and Health and the editor of its report to Congress, Action for Mental Health, could say in 1961, “Physicians who fancy themselves as medically respectable have tended to shun these places.”

It naturally follows that state hospital ward doctors have little social and professional prestige. Many see themselves as medical peons with M.D. degrees, holding restricted licenses good only in state hospitals at state hospital pay. Many bitterly resent their isolation, the compromises they must make with their medical ideals, their tremendous responsibilities, and the absence of recognition as they share and identify with their patients’ social rejection.

Unfortunately, the state hospital system is not likely to improve as a result of the recent passage of the Mental Health Act. The very excellent provisions of this act are focused exclusively on community psychiatry — that is, psychiatric activities and facilities outside the state hospital system. For this reason, current resentment against this act on the part of responsible state hospital personnel reflects their fear of further relegation into the background. One typical, traditional legislative failure in this field of mental health has repeated itself, The Mental health Act provides funds for buildings, but by specific intent excludes funds for salaries. Speaking as a psychiatrist, I also fear that the $329 million which this act anticipates spending will further emancipate professionals, the public, and legislators from their responsibilities for those already neglected by this act — namely, the half million actual state hospital patients.

Furthermore, as we will be continuing to neglect what Dr. William Menninger refers to as “things called hospitals [which] are human warehouses where people rot out their lives,” the whole program is built on sand. As long as back ward custodial hospitals exist in any jurisdiction and are tolerated, this social permissiveness encourages the community psychiatric facilities to shift to state institutions their potential failures and their most difficult cases — essentially those who need skilled help the most.

Public attitudes toward our large state custodial institutions and their inmates must change. Such a change can come about only through both awareness of the need and self-interest, two factors which can be cultivated. Obviously, if patients’ rights to payment for their nontherapeutic labors were established, their primary relationships would be changed. Also, the expense of paying the patients, or employees, rather than depending on institutional peonage, would increase the immediate outof-pocket costs of running these so-called hospitals. But the institutions would then have no need for any patient or his work, and restructuring will have already started. The next step would be the hiring of adequate doctors and staff to inhibit pathological dependency on the institution, to effect recoveries and separations, and reduce substantially hospital populations.