The First APA Mental Hospital Institute: A Reminiscence

Editor's Note: This year marks the 50th anniversary of the American Psychiatric Association's Institute on Psychiatric Services. The first institute—then called the Mental Hospital Institute—was held April 11-15, 1949, in Philadelphia at the urging of APA's first medical director, Daniel Blain, M.D. He saw it as an opportunity to give superintendents of the nation's overcrowded and underfunded state hospitals a chance to air their frustrations and to discuss what practical steps could be taken to improve the care and treatment of their patients. Reprinted below is a reminiscence about the first institute by the late Robert L. Robinson, who served as director of public affairs for APA from 1948 to 1979. The article first appeared in the October 1970 issue of Hospital & Community Psychiatry on the occasion of the institute's return to Philadelphia.

Never a man to make haste slowly, Dr. Daniel Blain called me into his office a week or so before Christmas of 1948. He had been on the job as the first APA medical director for less than a year, and I as chief of the information service for about four months. The following approximate conversation ensued.

DB: Robbie, we've got to do something for the mental hospital superintendents. They're taking a beating from the press. They think APA has let them down, and it has. Their situation is deplorable, but it's not all bad. I've visited scores of mental hospitals this past year, and in spite of their severe handicaps, I've seen a lot of fine patient-care programs going on. I want to bring them to light. I want to put an end to all of this negativism and pessimistic talk about the mental hospitals. I want to see some positive action.

RLR: Fine, Dan, I couldn't agree more. We've worked closely with our journalist friends Albert Deutsch, Edith Stern, Mike Gorman, and others to arouse the public conscience about the plight of the hospitals. They've done a great job, but unless we ourselves come up with positive leadership, their efforts won't result in any real gains. Have you thought any more about getting some foundation support to launch a service for the mental hospitals, like the work the American Hospital Association is doing for the general hospitals?

DB: It's a splendid idea, and we must work on it. But first let's call the superintendents together from all over the U.S. and Canada. I've been talking this whole matter over with our president, Bill Menninger, Dr. T [M. A. Tarumianz, M.D., then chairman of APA's Committee on Hospital Standards and Policies], and several others. We want to convene a mental hospital institute. We'll have it at the Institute of the Pennsylvania Hospital in Philadelphia; Kenneth Appel, Edward Strecker, and Lauren Smith all say they'd be delighted to have us. They've got a good auditorium, and besides there's a lot of sentiment associated with the place. It was there that APA's 13 founders first discussed the idea of a national association, in the home of the hospital's first superintendent, Dr. Thomas Kirkbride.

RLR: Sounds good to me, Dan. Shall we schedule it for next fall?

DB: No. We've got to move fast. I've already got the dates settled—next April 11-15.

RLR: But, Dan, for all practical purposes that gives us only about three months to prepare, and we have no money to begin with!

DB: We can do it. I've also worked out the money problem. We'll charge them a $50 registration fee.

RLR: Seems pretty steep to me. You think they'll pay it?

DB: Sure they will. In return we will include their lunches, throw a cocktail party and banquet, give them a tour and another dinner at Delaware State Hospital, and promise them a copy of the proceedings. Now, I'd like you to prepare suitable announcements and letters of invitation to be sent to the governors of all the states, to all the state commissioners, and to the superintendents of United States and Canadian mental hospitals, public and private.

RLR: O.K. What about the program content?

DB: Well, we've got the general idea worked out. What we want to do is to get the superintendents talking about what can be done now, under existing circumstances, to improve treatment and care in the mental hospitals. That will be the theme of the meeting. We'll build the program around four main topic areas—administration, personnel problems, clinical relations, and community relations. The superintendents will have a lot of complaints to get off their chest, of course, but I want to get them talking about positive steps that they and the APA can initiate right away to get the hospitals out of the quagmire they're in.

By the way, I almost forgot. I want to set up annual awards and invite all the hospitals to apply. I've got $250. We'll call them the Mental Hospital Achievement Awards. I have in mind citing one or more hospitals for specific accomplishments, such as relieving staff psychiatrists of administrative duties so they that they can devote more time to patients, starting training programs for aides, developing better teamwork approaches to patient care, and the like. We'll get a number of applications in and distribute copies of them at the Institute. It will be good for morale. Maybe we can publish them later on.

RLR: Fine. Now what about the faculty for the Institute?

DB: Well, I haven't got that worked out yet, but I don't want any formal papers. I want the superintendents to do the talking. They haven't had a chance to spout off in a long time. We'll confine our faculty members to merely introducing a topic to get the ball rolling. I have in mind calling on our top brass, chiefly Past-Presidents Winfred Overholser, Karl Bowman, and Samuel Hamilton. Of course, William Menninger will be there to open the Institute. And Walter Barton, Arthur Noyes, Juul Nielsen, William Terhune, and the two George Stevensons would be stimulating. Also, I will get Morris Fishbein [editor of JAMA] to be the banquet speaker.

RLR: Fine, Dan, I'll get with it.

DB: And by the way, invite your friends in the press to come too. The more publicity the better.

RLR: Will do.

A new approach to the problems facing the mental hospitals of the nation marked the Mental Hospital Institute held in Philadelphia. The men on the psychiatric firing line—the hospital superintendents—met under the auspices of the American Psychiatric Association to find out what they might do to comfort better the 650,000 patients in their care. On the surface, they are coping with overcrowding and personnel shortage, but there is the basic problem of lack of finances, which, in turn, is caused by inadequate public support.

For it is the general public that is really the No. 1 problem of the mental hospital officials. We, as a nation, cannot achieve even minimum standards in our mental hospitals until we learn to identify ourselves with the problem of mental illness as we do with cancer, tuberculosis and heart disease. It is encouraging, however, that the hospital superintendents are not waiting for the public to accept its responsibility but are going ahead on their own. They are frankly considering all issues, even unto the basic structure of the entire mental health system, so that eventually it will be designed "not for custody and palliation but for real treatment," as Dr. George S. Stevenson, president-elect of the association, puts it. We hope that their discussion will carry through to real achievement.

—Editorial, reprinted from the New York Times,

April 19, 1949

So it came to pass, after a frantic three months of preparation, that at 8:30 a.m. on Monday, April 11, 1949, President William C. Menninger welcomed 190 participants to the first Mental Hospital Institute. They came from 36 states, six provinces, Puerto Rico, and New Zealand. We worked them from 9 a.m. to 5:30 p.m. on each of the first four days and through lunch on Friday. Speaking of the lunches, Dan had a plot: if a light lunch—tomato juice, a sandwich, a pickle, and apple pie—was included in the registration fee, he said, people would eat it quickly and go back to work. They did.

He had me get him an old-fashioned school bell that either he or I could ring in the corridor to call people back into their seats for the next session. Moreover, he allowed them only Thursday night to go out on the town. We couldn't get away with such a schedule today. But we did then. The superintendents loved it.

It was a marvelous catharsis for them. Their long-felt resentments rushed to the surface. Why had APA forsaken the hospitals? they demanded. How long, oh Lord, how long must they run their institutions on $1.50 a day per patient? Could nothing be done to halt the intolerable political interference they had to contend with day in and day out? Who wants to preside over such snakepits? Dr. T made such resounding statements as "Your hospital stinks. My hospital stinks. They all stink," and "Mental health has been a stepchild of public welfare for the past 200 years!"

The catharsis soon took its therapeutic effect. Confident now of APA's interest, they let their despair give way to resolute regrouping of ranks for an all-out fight against the plagues that beset them. At the final luncheon meeting, the late Dr. Clifton T. Perkins, who presided at the time over Massachusetts hospitals, trumpeted William Lloyd Garrison's famous exhortation to express the group's sentiment: "I am in earnest. I will not equivocate; I will not excuse; I will not retreat a single inch; and I will be heard."

Shortly after the Institute, Dr. Winfred Overholser said that it had taken "mental hospital doctors out of the category of forgotten men and placed them back where they belong as the first priority of the APA." The New York Times editorialized that "A new approach to the problems facing mental hospitals of the nation marked the Mental Hospital Institute held in Philadelphia… the mental hospital superintendents are not waiting for the public to accept its responsibility but are going ahead on their own… We hope that their discussions will carry through to real achievement."

The positive note that Dan Blain wanted had been sounded. Of course, the Institute was only the beginning move in his favorite game, called "Lifting Oneself by One's Own Bootstraps." Right after the Institute, he helped me develop a formal proposal for the Mental Hospital Service and we sent it to the Commonwealth Fund, where we had a friend of long-standing, Mildred Scoville. The fund sent us a check for $44,500 to get the service under way, which we did the following January with the publication of a four-page mental hospital bulletin. Under the leadership of Pat Vosburgh, who joined the staff in 1951, it later became Hospital & Community Psychiatry [now Psychiatric Services]. Late in 1950 we did publish the earliest applications for the Achievement Awards in an attractive pamphlet called On The Positive Side. This was perhaps the only encomium that mental hospitals had received since the middle of the 19th century. That same year the Central Inspection Board, under the leadership of Dr. T and the chief inspector, Dr. Ralph M. Chambers, swung into full gear, giving citizens for the first time a professional measuring stick to gauge the poverty of their mental institutions.

The consensus at the Philadelphia meeting left no doubt that the Institute would become an annual event, and that succeeding ones would be open to all hospital personnel. (Many groups, including the superintendents, have since formed organizations of their own, which meet annually in conjunction with the Institute—now called the Institute on Hospital & Community Psychiatry [since 1995, the Institute on Psychiatric Services].

At last the entire mental hospital family had a forum where they could discuss issues large and small. Some of these issues have had widespread repercussions. APA President Kenneth E. Appel used the 1953 Institute as his platform to alert the nation to the need for the Joint Commission on Mental Illness and Health, which Congress authorized in 1955. That commission's stirring final report, Action for Mental Health, led to—but that's another story. Suffice it to say that many of the seeds of psychiatry's "third revolution" were planted in Philadelphia in mid-April of 1949.

With Pennsylvania embarking on a new program of treatment and care for the mentally ill, there is special significance in the warning by Dr. George S. Stevenson, president-elect of the American Psychiatric Association, now meeting here, that it's not the Governors and State officials who are to blame for the comparative deterioration of the nation's mental hospital so much as it's the refusal of the public to "face its own fears."

When the average citizen realizes and accepts the need for real psychiatric care for the mentally ill, and is willing to pay the bill, it is unlikely that any State will hold back from putting a least a minimum program into effect. Given the support, Governor Duff certainly has been eager to do as much as possible, within the powers granted to him. But the job, particularly for the Nation as a whole, is a tremendous one, for which even by the most optimistic appraisal, ten years will be required to assemble the bare necessities in equipment and personnel.

Before we can pass the lowest acceptable standards, thousands of psychiatrists must be trained, hundreds of buildings constructed and the money granted to maintain them. Such a sweeping operation can only come from a deep and enlightening public spirit, ready not merely to criticize the politicians and medical people, but to get behind the projects with votes, funds and active campaigning.

Members of the American Psychiatric Association in their discussions are doing yeoman service to this end. It's up to them, when they return to their various homes, to provide the leadership and drive for a Nationwide movement of this sort.

—Editorial, reprinted from the Philadelphia Inquirer,

April 14, 1949