Rational Buildings Designed To `Calm the Disorderly Mind'

On August 26, 1993, 135 years of caring for people with mental illness came to an end as the last 17 patients at Northampton State Hospital in Massachusetts were helped out the doors to new lives in other settings. At its peak in the 1960s, Northampton State housed 2,657 patients and employed more than 500 staff. Once a monument to enlightened care, the asylum complex lay abandoned for a dozen years, a spooky shell, partially demolished, until sections were redeveloped as a mixed retail and residential project.

Northampton State's fate mirrors that of the great imposing mental hospitals that once dominated psychiatric treatment in the United States the way their buildings dominated local landscapes. Their design—often by leading architects—embodied their era's best psychiatric thinking.

The 19th-century asylums were that era's answer to the degrading incarceration by families or local authorities of those incapable of looking after themselves.

“In 1820, only one state hospital for the mentally ill existed in the United States,” Gerald Grob, Ph.D., a medical historian at Rutgers University who studies the history of mental illness in the United States, has written. “By the Civil War, virtually every state had established one or more public institutions for that purpose.”

There were earlier American hospitals used for the care of mentally ill people. One was opened in Philadelphia in 1752 and another in Williamsburg, Va., in 1773, but these were custodial institutions.

Reformers like Dorothea Dix traveled through Massachusetts and other states, documenting men and women locked in filthy cages, penned like livestock in stalls, or shuttered away in almshouses. State legislatures soon responded. They assumed financial responsibility for mentally ill individuals and then carried out that obligation using a new approach termed “moral treatment.” Drawn from earlier British and European models, moral treatment embraced an enlightened medical model of insanity, supported by a belief that patients could be treated with some hope of success, like those with physical disease, rather than merely confined.

Moral treatment also required a change in environment, a removal from dysfunctional homes and corrupting cities, said Grob, so proponents of the approach often chose isolated, mid-state locations, like Utica, N.Y., or Northampton, Mass., or Milledgeville, Ga., although others were in or near large cities.

Some patients were long-term residents, but most were admitted, treated, and released in periods of less than a year. All social classes may have been represented, according to Grob, but the hospitals met a need for those patients who were severely ill and had no families or whose families couldn't cope.

“Patients would live a regimented life, eat healthy food, get exercise, avoid the vice-ridden city, and visit daily with the superintendent or his wife, the official matron of the institution,” wrote Carla Yanni, Ph.D., an assistant professor of art history at Rutgers University in the March 2003 Journal of the Society of Architectural Historians. Medical treatments were included in this regimen, too. “They typically gave opiates, warm baths, cold baths, and an arsenal of laxatives.”

Architecture as Therapy

This new therapy could not be provided in old buildings, believed the psychiatrists of the day, many of whom were founders of what became APA. Several new asylums were built on linear or hollow-square plans, but the classic structure was based on the Alabama Insane Hospital, designed by Samuel Sloan and built in 1852, and codified by Thomas Kirkbride, M.D., in an influential 1854 book.

The “Kirkbride Model” called for a large building constructed symmetrically on either side of a central administration building that was flanked by attached wards set back in steps—“like a row of birds in flight,” in Yanni's phrase. The division into setback wards allowed more severely ill patients to be placed by themselves, in the wards farthest away from the central building. The central building contained offices and housing for the superintendent and his family and marked the boundary between men and women patients, who were housed in separate wings.

The shallow V of the Kirkbride model offered several other advantages. Patient rooms were usually on only one side of the building and so had the same views, views often enhanced by the work of expert landscape architects. Both physicians and the architects were intensely concerned about ventilation, for reasons of comfort and also possibly a carryover from the miasma theory of disease origin, said Yanni.

“Building patient rooms only on one side was more expensive, but it was better for surveillance and ventilation,” said Yanni in an interview. “It meant never having to turn your back on a patient.”

By 1890, about 70 Kirkbride-style asylums had been built in the United States.

Many landscape architects designed asylum grounds as well as great city parks. For example, Andrew Jackson Downing laid out the National Mall in Washington, D.C., as well as the grounds of New Jersey State Lunatic Asylum at Trenton in 1845 and the sprawling North Carolina Hospital for the Insane, outside Raleigh, which opened in 1856. Frederick Law Olmsted designed New York's Central Park and the grounds of Buffalo State Hospital. The buildings of Buffalo State Hospital were designed by famed architect Henry Hobson Richardson, the first building in what became his signature neo-Romanesque style.

Ironically, Olmsted also planned the grounds of McLean Hospital, outside Boston, where he was a patient in his last years.

Olmsted and Downing idealized a life close to the land. “They believed that human behavior could be explained by environmental factors, that nature was curative, exercise was therapeutic, and cities were a drain on the psyche,” said Yanni. “Patients rose early and often spent the morning outdoors in good weather. After lunch, middle-class patients read and played games, while working-class patients worked on the farm or in the print shop.

“If the old buildings are today perceived as inhumane, they were representations of the most advanced thinking in the 19th century when they were built,” she said. “Doctors believed that rational buildings would calm the disorderly mind.”

Modern Psychiatry Dawns

Many institutions often had success with what today would be called short-term interventions. However, the 19th century also saw a rising tide of patients suffering from then-incurable psychiatric complications of syphilis and alcoholism. The need for a high ratio of attendants to patients meant that asylums became overcrowded institutions, custodial rather than curative.

From 1890 to 1950, the tide turned. State mental institutions became surrogate old-age homes, and more than half the admissions were of people over 65, said Grob. “If they could define senility as a psychiatric problem, the localities could pass the care—and costs—to the states.”

By the mid 20th century, 75 percent of patients were not only old but had no relatives to care for them. Mental institutions became even more custodial until radical change arrived in the 1950s and 1960s.

The introduction of psychiatric drugs like chlorpromazine meant that some mental patients could be treated on an outpatient basis, allowing more of them to lead lives less constrained by walls and bars.

Psychopharmacology was not the only factor to affect the status of asylums. The ascendancy of Freudian therapy, the experiences of conscientious objectors who worked in asylums during World War II, the beginnings of an antipsychiatry movement, and the promotion of community mental health centers steered the focus of mental health treatment away from the large mental hospitals after the war.

“But perhaps the most important cause was financial,” said Grob. “The passage of Medicaid and Medicare redefined senility in psychiatric terms and sent patients to chronic care institutions. This was a lateral shift from mental hospitals to nursing homes, which were eligible for Medicaid funds. Other entitlement programs, passed in the 1970s, contributed even more to the movement out of mental hospitals.”

Psychiatric spaces also changed with the times, said Yanni.

“After World War II, there was a wave of modernist design in psychiatric architecture. The design of that era favored white walls, linoleum floors, no applied ornament, and windows that didn't open. People believed that this clean, hygienic design created a controlled environment.”

Eventually, this antiseptic style was viewed as cold and harsh, she said. There followed a movement to return to a system of cottages or small dormitories spread across asylum grounds, which had a prior flowering early in the 20th century.

In the 21st century, design of mental hospitals reflects newer concerns, like privacy. The new 192-bed building at the private Sheppard Pratt Health System in Towson, Md., serves as an example. It replaces the original 1891 structure designed by Calvert Vaux, who worked with Olmsted at Buffalo State. The building has two sets of corridors, one permitting limited access for visitors and another to allow patients and staff to circulate out of sight of outsiders. Consulting rooms are located near the entry to units for greater privacy. Nurses' stations are not at the end of the wards but in the center, with short corridors radiating outward for better visibility. Units are built on the same plan but vary, depending on patient needs. The adolescent wards have bench beds, and showers in the bathrooms are on 90-second timers so young patients don't stop up drains and walk away. In the adolescent neuropsychiatric unit, the nurses' station also has glass panels to protect the desk from unruly patients. Extra sets of doors permit lengthening or shortening the corridors connected to the main building as the patient census changes.

Many Stubbornly Survive

While 19th-century buildings have gone out of use, said Yanni, few have actually disappeared.

“Places like Northampton are physically difficult to tear down,” she said. “They are enormous. Some are half a mile long. They are usually made of stone, and all the walls are load bearing, down to 10x14-foot patient rooms. Many were fitted with asbestos-coated pipes in the 1950s, and the abandoned ones are full of rabid cats. So the state-owned ones just sit there.”

The fates of others vary. The older, west campus of St. Elizabeths in Washington, D.C., is boarded up while crews work to stabilize the 56 buildings on the site. State government offices are slowly taking over Harrisburg State Hospital in Pennsylvania as patients move out to community settings. The farm formerly attached to Buffalo State Hospital is now occupied by Buffalo State College. Parts of Richardson's buildings, now on the National Register of Historic Places, are occupied by the Buffalo Psychiatric Center, and talks are under way to use other areas for a school. The former hospital in Traverse City, Mich., has been developed into a mix of retail and residential condominium space.

Old asylums seem to fascinate some. The ghost of Northampton echoed to a special sound installation prepared by German-American artist Anna Schuleit in November 2000, which otherwise lies idle while the state decides what to do with the property.

All told, more than 250 asylums were constructed in the United States in the 19th century, an enormous commitment of public will and funding, said Yanni. Yet the field they were erected to serve has progressed through so many stages—of which only the latest is deinstitutionalization—that now they are viewed as relics. Whatever their present state, asylum buildings represent a physical memorial to the patients and those who cared for them for almost 200 years.

If “architecture manifests scientific knowledge,” as Yanni observed, then the crenellated palaces and castles of 19th century insane asylums certainly expressed in brick and stone their vision of psychiatry.

“They remain as witnesses to the history of medicine and testaments to a once-common faith in environmental determinism,” said Yanni.

More about 19th century asylums is posted at<www.abandonedasylum.com>,<www.1856.org/main.htm>,<www.kirkbridebuildings.com/index.html>.▪