This historical record of Oregon’s first state hospital, the Oregon State Insane Asylum, from its opening in 1883 until the mid-1950s, will focus on the experiences of patients there. This is in contrast with the typical chronological history of who served as superintendent, for how long, the date new buildings were opened and other such changes.
The guiding principle for the hospital during these seven decades, whether recognized or not, was “Everything About Us Was Without Us.” There was little attention given to the value and contributions of those who were “patients” there.
Some may argue that the history presented here imposes a contemporary perspective on a hospital that existed many years ago. However, this history shows how residents were deprived of making decisions about themselves, and it tells of the treatments, practices and policies of the hospital.
As such, it tells of a reality of people’s experiences during those seven decades. And therein is a critical lesson for today’s mental health system, and how it should strive to ensure that everything about us is with us, not without us.
Opening the New Hospital
The need for a state hospital in Oregon arose because of the increasing numbers of people with mental disorders being admitted to the existing Hawthorne Asylum, which had opened in 1862 (which I wrote about previously here). Planning for a larger state hospital began in the mid-1870s, and by 1882, the patient census at Hawthorne Facility had grown from 7 to 327.
The Oregon State Insane Asylum opened in 1883. The building was based on the Kirkbride model. Thomas Kirkbride was a Quaker physician who had served as the superintendent of Pennsylvania Hospital for the Insane from 1840-1883. He believed his architectural design was therapeutic and helped with recovery. This was an extension of the moral therapy that guided the Hawthorne facility.
The 327 patients from the Hawthorne Asylum in Portland were transported by train, with blinds covering the windows, to the new hospital in Salem. They were in the “dark” and suddenly living in a new place.
A problem that quickly arose was a rapid turnover of leadership. Although most superintendents were qualified, rather than politically appointed, there were five new ones in the first eight years. If moral therapy was the goal, this was not a promising start, as the superintendent was meant to serve as a guiding figure.
Overcrowding also quickly became a perpetual problem. The patient census at the hospital increased from 350 in 1884 to 3,500 in 1956. As this census grew (as was the case with the 190 other state mental hospitals in the US), the hospital struggled to develop quality leadership and with a deficit of resources: staff turnover, lack of staff, hiring of unqualified attendants who could be abusive, underfunding, and deteriorating buildings.
Life at Oregon State Hospital
In 1913, the Oregon State Insane Asylum was renamed Oregon State Hospital (OSH).
There are reports from surveys in 1921 and 1940 that provide a glimpse life at OSH during this period. Not surprisingly, these surveys included no input from people who were there as patients. If these surveys had sought responses from patients, there would have been a serious inquiry into the practice of sterilization during this period and electroshock treatment. Lobotomy arrived in the 1940s. Other treatments seen as abusive today, hot and cold baths, and swaddling with sheets, were mainline treatments. However, there was no inquiry into the merits of such treatments; there were simply assumed to be a regular part of asylum care.
1921 Survey
This survey was commissioned because of dissatisfaction with how the mentally ill were being “handled,” and to plan for future need. The survey told of how some buildings were already considered “out of date” with narrow windows and poor lighting, and that there was a lack of treatment facilities. Other deficiencies included underfunding, overcrowding, a need for unspecified changes to civil commitment and sterilization laws, improved education with a closer relationship to the medical school, and better treatment for the mentally ill in other hospitals and almshouses. The survey noted a need for more school classes for “defective children.”
1940 Survey
This survey was conducted by the United States Public Health Service at the request of Governor Charles Sprague to the Surgeon General of the United States. Both OSH and Eastern Oregon State Hospital were visited. In addition to the onsite visits, the survey drew on a variety of documents. However, like the survey in 1921, this one did not involve interviews with either patients or their families. As such, it serves as a prime example of “everything about us without us.”
The survey reported that the census in 1940 was 2,677, more than 500 over capacity. This statistic can be dryly reported, but it meant if you were a patient, you would have been sharing a room with two, possibly three other people.
While the dining room was a large one, it was overcrowded. Bathrooms were also not in accordance with comfort and sanitation, and in some places you were sharing a toilet with 40 other patients. Many bedroom doors had no knobs on the inside so patients could be locked in. The survey noted that though older buildings were “good in their day, they carry fire risk.” Those on the third floor were at serious risk if a fire broke out. Given that risk, the survey rather casually mentioned the need for fire drills and sprinklers so that help was “not too far away” in case of fire.
In her book Inside Oregon State Hospital: A History of Tragedy and Triumph, Diane Goerse-Gardner describes how, shortly after the discovery of insulin in 1922, OSH started using it to induce a seizure and sometimes a “near death” coma. This treatment was often given to younger patients diagnosed with schizophrenia, and those who were considered “the cream of the crop,” Gardner wrote.
Those who were deemed cured sometimes had as many as 40 such treatments. There is no doubt that these “treatments” made the patients more “manageable.” Insulin shock therapy was then somewhat replaced by Metrazol shock therapy, which was introduced in the 1930s and induced such violent seizures that patients often suffered broken bones.
As for the 1940 survey, it made no mention of insulin or Metrazol treatments. Nor was there any mention of surgical lobotomies, which had been recently introduced. However, there was a favorable reference to hydrotherapy as a way to calm patients.
The survey did tell of how understaffed the hospital was. While national standards called for one attendant for every four patients and one physician for every 150 patients, in 1940 there was one physician for every 333 patients and one attendant for every 12 patients. Many of the attendants weren’t qualified and some were abusive. The survey took note of a “fair amount of mechanical restraint” with many patients fastened to their beds in part due to inadequate staffing. Large numbers of patients didn’t leave their wards for months at a time. There were patients who had been in restraints for as long as eight and a half years. The number of women in restraints was quite large.
The published report also provided examples of patients being abused, such as when an attendant put a female patient in straps and cuffs and locked her to a chair and then bashed her and shook her against the wall. Even though most of the attendants who abused patients were fired, it created an atmosphere of fear which was not fully understood or dealt with.
A firsthand account of the environment from the time of the 1940 study came from an article co-authored by a patient and published in the Sunday Oregonian:
“Some of the patients there are violently insane and even dangerous, but they are locked in. Some of them scream, but you soon become accustomed to that. Some talk incessantly, often choosing nighttime for their loudest tirades. Some were still screaming.”
Here is another patient account from this time, that was not incorporated into the survey.
“My treatment at Oregon State Hospital left me with no sense of smell, a facial tic, memory loss, impaired vision, loss of interest and other permanent problems. But staff had voted on giving me this treatment. My family agreed for me to have it. I didn’t agree. It’s true that sometimes I was a real problem on the ward, and it made me a lot easier to manage. But I was never the same and I remained in the hospital for years to come.”
Without going into details, the survey stated that “some patients have died violently.” Further risks for patients and staff came from deadly diseases like typhus, typhoid fever, and water supply poisoning. However, the 1940 report stated that clinical histories of patients were too reliant on statements from the patients, and thus couldn’t be trusted, as the patients weren’t “objective.” Indeed, the survey stated that they found relationships between staff and patients to be “friendly.”
The hospital operated a farm with patient labor so that it could spend relatively little cash for food products. A considerable number of men, estimated at 300, worked on the farm. The practice of using patient labor for various tasks around the hospital was partly responsible for a patient helping in the kitchen in 1941 who mistakenly picked up a poison after being given a key to the hospital pantry and mixed it into the morning’s scrambled eggs. It caused 47 deaths, and an additional 500 patients and staff became extremely ill.
In contrast to the traumas that patients may have suffered, there were some elements of the building and daily events that reflected moral therapy precepts. The Kirkbride blueprint led to the presence of a library, a chapel, a chapel, a choir, two auditoriums each with a piano, and many radios. There were beautifully designed stairways to add an air of dignity to the hospital, which was supposed inspire patients to behave accordingly. For entertainment there was croquet, concerts, holiday dinners, radios, movies, and a men’s softball team. Selected patients were allowed to attend the state fair in Salem and go on picnics. The grounds were “beautifully kept.”
The report ended without recommendations.
The Tarrytown Tattler
The hospital patients produced a newsletter, The Tarrytown Tattler, which ran through the 1940s. Hospital staff would have had to approve the content before it could be published; the newsletter presented a very positive picture of life during this time—a period were the hospital was severely overcrowded, some patients were held behind bars, and many were subjected to sterilization, ECT, and lobotomies.
The Tattler was written by ward representatives, and carefully typed. It reported on many social, recreational, and work activities. There were card games, story writing contests, choirs, tennis, spelling bees, table tennis, badminton, baseball, and men’s football teams. There was a slapstick stage production with “a hilarious half hour of slapstick, hillbilly style.”
Work was seen as valuable in settings like the bakery, the kitchen, laundry, even a butcher shop. One Tattler “reporter” told of how it was important to “see the funny side of life.” Patients were advised to “help defeat Hitler by calling him by his right name, Schicklgruber!” The ward reports are full of such humor.
On the back page of each edition, the Tattler provided a count of people who had been discharged, along with the declaration that “mental illness can be cured.” There were many examples too that told of caring and helpful staff. Perhaps the Tattler provides us with a lesson today: how patients find ways to manage traumatizing experiences with such human touches.
Institutional Anosognosia
Anosognosia is a term used today to describe someone who is struggling with mental health challenges but who lacks “insight” into his or her illness, and thus may object to “treatment.” The Cleveland Clinic describes anosognosia as “a condition where your brain can’t recognize one or more health conditions or problems you might have.”
When researching this history of OSH, I came to think of the presence of “institutional anosognosia” during this period. Despite the obvious damage that lobotomies, the various kinds of shock treatment, and sterilization caused, the state hospitals didn’t recognize the harms that such treatments could cause. One could argue that that “institutional anosognosia” remains present today with the system’s overuse of psychiatric medications.
Sterilizations
The history of sterilization is not covered in most accounts of OSH. Along with vasectomies, some patients were castrated. Sterilization procedures for women ranged from tubal libation to bilateral salpingectomy.
These practices arose from a eugenics movement that sought to prevent the “mentally ill” or “mentally retarded” from passing on their bad genes. A 1930 superintendent’s report stated that by that time, 193 patients had been sterilized. “Sterilization of the insane of child-bearing age is very important,” said the long-time superintendent, Dr. R. E. Lee Steiner. He was opposed to a law passed by the legislature that required the patients to consent to be sterilized, and he was pleased when the state legislature removed the consent requirement. Between 1918 and 1941, there were 509 sterilizations, 59% of whom were women.
“No untoward or unfavorable results have occurred,” wrote Dr. Steiner. His hope was that “increasing enlightenment will cause these operations to be resorted to much more extensively in the future.”
Electroshock
Electroshock (ECT) was first administered at OSH in 1940 and soon became a routine treatment for depressed people. ECT has almost entirely been reported in statistics, mainly by numbers of people shocked and not by observing the devastating effects.
Records of ECT were not reported until 1946, but here are the numbers after that time: there were 6,854 ECT treatments from 1947-1949; 12,645 from 1950-l951; 22,645 from 1952-1953; and 16,378 from 1954 to 1956. During the busiest two years, this comes down to five ECT treatments per hour, eight hours a day, or 40 ECT treatments every weekday. That is a tally of a great amount brain damage.
There are not many firsthand accounts of what patients at OSH experienced because no one bothered to ask them. However, there is one vivid story recorded by Gardner in her book. A minister, David Snider, was first admitted to the hospital in 1947, and within three weeks had been electroshocked. During the time he was waiting to receive this treatment, he was forced at one point into walking 150 feet nude and cold from a hydrotherapy session to his room. On his second admission, he had another incident with a couple of drunk attendants, after which he was subjected to another series of ECT “treatments.”
Here is another patient account of how electroshock was practiced at this time (although this patient was not at OSH):
“You would see seniors and others being tied to chairs a good part of the day waiting for the ECT. You would eventually see a staff person come across the room with the ECT equipment. To gain a sense of protection you would curl up with a sheet but then staff would uncover you when it was almost your turn and you would try to see how the person in front of you to see what they were doing to her. You see would see your friend shake violently when administered the shock. Then you would have a jelly substance rubbed onto your temple and hear the staff probably speaking to each other, not to you—“Are you ready?” You would likely expect to die. You may have actually observed a friend die. You would wake up with a severe headache and your mind would be blurry. You might lose months of memory and some loss of self-esteem. You might even become catatonic. Your brain likely didn’t work as well. You wouldn’t have volunteered to be administered the electrical shock and would certainly not be told how the treatments would affect you. There were other long term effects like difficulty concentrating. You just weren’t the same. No matter whether staff thought you were improved, that would not have been your experience. You would have been traumatized and damaged for life. Obviously, this is not waking up a little confused.”
Lobotomies
On August 26, 1947, superintendent J. C. Evans made a request to Oregon’s State Board of Control to approve the use of lobotomies at OSH. He claimed that relatives were “clammering (sic) for the operation,” and described it as “standard procedure.” He informed the Board of Control that it “consists of trephining the skull in the temporal frontal region . . . (with) a specially constructed instrument, a thin, sharp knife like a blade about four inches long.”
Evans said it was “particularly recommended in patients who are suicidal, profoundly depressed, resistive, having to be tube fed, etc. It brings about an immediate change in personality and habit patterns.”
His request was approved. Between 1947 and 1954, 135 lobotomies were performed on OSH patients.
The staff at the hospital would describe a patient who had been lobotomized as much more “tractable.” Gardner, in her book, tells of how a woman who was subjected to a lobotomy “will probably be capable of remaining at home, but it will be necessary for her to have supervision at all times. She has to be watched like a child and told what to do all day long and she can be quite critical and sarcastic if things don’t suit her. The mother inquired about the possibility of bringing her back to the hospital if necessary.”
The last biennial Oregon report on lobotomies was provided in 1954, but these surgeries continued with the approval of the Board of Control. Between 1973 and 1981, after a decline in the number of lobotomies, the Board of Control still approved five of six lobotomy requests. According to Gardner, the last lobotomy in Oregon was performed in 1981.
The Shame of the States
After the end of the war, Albert Deutsch published The Shame of the States, a blistering account of the deteriorated conditions inside the country’s state mental hospitals. He visited 10 of the 190 state mental hospitals in the country, and while he didn’t visit OSH, he did describe how conditions were much the same at all 10 he visited, and thus much of his report could have been applicable to OSH as well.
He told of how on the outside, many of the hospitals—with their Kirkbride architecture—still presented a grand façade. But once inside the facilities he told of scenes that shocked the public, comparing them to what he had seen at Nazi concentration camps. “I entered buildings swarming with naked humans herded like cattle and treated with less concern, pervaded by a fetid odor so heavy, so nauseating, that the stench seemed to have almost a physical existence of its own,” he wrote. “I saw hundreds of patients living under leaking roofs, surrounded by mold, decaying walls and sprawling on rotting floors for want of seats or benches.”
A visit to the OSH Museum in Salem shows that this tableau of overcrowding and poor conditions existed there too, at least to some extent.
History Lessons
What can be learned from this history of Oregon’s first state hospital?
One obvious lesson is that the larger the program, the more unlikely that it can adopt a moral treatment model. Even back in the time of the Hawthorne facility, a census of 250 was considered too large. Like most other state hospitals, OSH never had a chance to institute moral treatment even though its earliest leadership had been working at the Hawthorne facility. From its beginning, even if there was a desire to do something similar, it had to serve more people than it could realistically support with this model. Were patients ever asked how they felt about sterilization, lobotomies, or electroshock? Staff assumed mostly that medical interventions like these were acceptable because medical leadership said they were. Could this apply to the reliance on medication? It is clear that today’s psychiatrists are still largely trained to accept this treatment culture.
There are far too many examples at OSH of institutional anosognosia, and this characterization applies not only to state hospitals but also most community mental health programs and facilities. The basic question is this: Does the program have insight into itself and its problems and challenges?
Simply becoming aware of the concept is a start. Programs are rarely aware that while what they’re doing may be well intended their actions and treatments may be harmful or at least miss important marks. Some questions to ask are these: Has the program considered the degree to which the medical model guides its services and supports? Are peer supports considered foundational, or a sideline element?
Are alternatives to psychiatric medications a mainstay? Does the program offer deprescribing services? Has the program implemented a meaningful peer council to get regular feedback—and to assure an honest evaluation of the program—from peers? Is the system trauma-informed?
A related question is whether program management recognize that the most mental health systems have rarely engaged peers, and that even when an effort to engage peers is started, systemic cultures and practices don’t happen quickly.
All of this is to say that programs should reverse the frequent practice of “everything about us without us” and make it routine to implement “nothing about us without us.” In other words, just ask people about their experiences. Do they feel like consumers only, or that their experiences as peers must be respected and are in fact the keys to good system design and operation?
There must be a commitment to counter institutional anosognosia.