The Practice of Psychiatry in General Hospitals

By A.E. Bennett, Eugene A. Hargrove and Bernice Engle

This title is part of UC Press's Voices Revived program, which commemorates University of California Press’s mission to seek out and cultivate the brightest minds and give them voice, reach, and impact. Drawing on a backlist dating to 1893, Voices Revived makes high-quality, peer-reviewed scholarship accessible once again using print-on-demand technology. This title was originally published in 1956.

• Language: English
• Publisher: University of California Press
• Release date: Nov 15, 2023
• ISBN: 9780520346000

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The Practice of Psychiatry

in General Hospitals

The Practice of Psychiatry in General Hospitals

A. E. BENNETT, M.D.

Associate Clinical Professor of Psychiatry,

University of California, School of Medicine, San Francisco;

Chief of Psychiatry, Herrick Memorial Hospital, Berkeley.

EUGENE A. HARGROVE, M.D.

Assistant Professor of Psychiatry,

University of North Carolina, School of Medicine, Chapel Hill.

BERNICE ENGLE, M.A.

Research Associate, Department of Psychiatry, University of California, School of Medicine, and The Langley Porter Clinic, San Francisco.

with contributing authors

UNIVERSITY OF CALIFORNIA PRESS

Berkeley and Los Angeles • 1956

University of California Press • Berkeley and Los Angeles, California

Cambridge University Press • London, England

Copyright, 1956, by The Regents of the University of California

Library of Congress Catalog Card Number: 56-8472

Printed in the United States of America

Mental disease is a medical problem and every general hospital should set aside ten percent of beds for psychiatric cases. This does more to overcome prejudice and fears about mental illness than does any other method of public education.

FRANK F. TALLMAN, M.D.

The establishment of psychiatric facilities in general hospitals eliminates the medieval idea that general hospitals cannot care temporarily for mentally ill patients. Every general hospital has at all times a large number of psychiatric pa- tients, the nature of whose difficulties is not recognized. We do not need more beds in state hospitals. If we had facilities in general hospitals for early treatment of psychiatric disordersy thousands of patients would not be sent to state institutions. The people should be alerted to this fact and insist that the community hospitals provide these facilities. Psychiatric wards in general hospitals are one of the best health investments society can make.

WILLIAM B. TERHUNE, M.D.

Foreword

Daniel Blain, M.D.

Medical Director of the American Psychiatric Association; Associate Clinical Professor of Psychiatry, Georgetown University, School of Medicine

A few properly planned and equipped rooms should be available in every general hospital for patients who need psychiatric care. This need, in every community, is too obvious to be argued: mental illness should be treated on a par with all medical and surgical conditions. Patients who need psychiatric care should be able to get it promptly from psychiatrically trained physicians in hospitals equipped to provide immediate treatment, with facilities for treating other types of illness close at hand.

So far specialists in mental illnesses have been unable to reduce the number of patients requiring psychiatric care to less than half the number of all hospital beds in the United States; nor have they been able to staff adequately the large mental hospitals placed in localities far from medical centers. Neither have psychiatrists been able to handle the entire load adequately. Consequently the burden of care and treatment of this type of case must be shared between the specialized mental hospitals and the general hospitals in the smaller localities. The burden must be shared by both psychiatrists, as specialists in the field, and other members of the medical profession, who are often able to handle many of the problems which occur in the earlier stages. Some provision must also be made in community hospitals to care for those temporary psychiatric complications which so often arise in toxic and debilitative conditions in various medical and surgical entities.

The establishment of psychiatric sections in general hospitals, the expansion of outpatient clinics, and an increase in the treatment facilities of large mental hospitals constitute the three great hopes for meeting the needs of one of the largest categories of sick individuals in the country. In recognition of this fact, the Department of Medicine and Surgery of the Veterans’ Administration adopted, in 1946, the policy that all general hospitals under its jurisdiction should make from twenty to thirty per cent of their beds available for the treatment of psychotic, psychoneurotic, and neurological cases.

All general hospitals should be prepared to meet this need in order to serve their communities. The psychiatric section, to achieve its best result, must be designed for psychiatric treatment in all its phases, including specific physical, clinical, and psychological approaches—not as a ward in which to house a disturbed patient until transfer is arranged.

The attention and interest of both the public and the medical profession should be aroused by the work of Dr. Bennett and his associates. Much credit is due them.

Introduction

Karl M. Bowman, M.D.

Professor of Psychiatry, University of California, School of Medicine, San Francisco; Medical Superintendent, The Langley Porter Clinic; Past President, American Psychiatric Association

In the beginning, all sickness was regarded as punishment by an angry God. It was gradually recognized that physical sickness had ordinary physical causes, but the lingering superstition about mental sickness led to the confinement of persons suffering from mental disorders in prisons—even to their torture or execution. Three hundred years ago the patient with hysterical anesthesia would have been looked upon as possessed by evil spirits and would have been burned at the stake.

Such ideas changed slowly, and it was not until the early nineteenth century, following the work of Chiarugi in Italy, Pinel in France, and Tuke in England, that the mentally sick were removed from prisons and dungeons and given humanitarian care. Many persons considered Pinel insane, since they felt that no sane person could suggest such a preposterous and ill-advised idea.

The new institutions for the mentally sick in Great Britain and the United States were called asylums or retreats: the term hospital was rejected because it was felt that it would disgrace respectable persons who were suffering from mental disorders to send them to institutions labeled hospitals, since only paupers went there. For over a century the lunatic asylum was literally a place of refuge for the mentally sick and for those who took care of them. Psychiatry was thus isolated from the rest of medicine, to the detriment of both psychiatry and medicine.

It is true that a few general hospitals have always had wards for the mentally sick: Bellevue Hospital in New York City, one of the oldest hospitals in this country, is one of these. Only within the last fifty years in the United States, however, have we seen the return of psychiatry to the rest of medicine, and the mentally sick no longer entirely isolated in asylums well out in the country, far away from general hospitals, medical schools, and other medical organizations.

Recently psychiatric hospitals have been built side by side with general hospitals. In a number of states the state itself has erected a small psychiatric hospital to operate in conjunction with a general hospital and medical school: early examples were the Michigan State Psychopathic Hospital and the Boston Psychopathic Hospital. Private psychiatric pavilions have been built as a part of general hospitals: for example, the Phipps Psychiatric Institute in connection with the Johns Hopkins Hospital. With this has come the demand to abandon the terms asylum and retreat, because of the stigma of these names, and to use the word hospital instead. However, with a few notable exceptions, general hospitals have only recently begun to accept mental patients.

General hospitals have traditionally excluded certain groups of patients; principally those suffering from highly contagious diseases, so-called venereal diseases, alcoholism, drug addiction, and mental disorders. In recent years these prejudices have gradually decreased, and the general hospital has tended to become a general hospital in fact as well as in name. The American Hospital Association recently recommended allocating three per cent of hospital beds for alcoholics. So-called venereal cases would generally be admitted at the present time, but this is not necessary, since most of them can be quite satisfactorily treated as outpatients with the newer antibiotic drugs. The general isolation procedures for contagious diseases are slowly disappearing. Even persons with leprosy (Hansen’s disease) are now at times accepted in the general hospital. Gradually, too, psychiatric wards are becoming an integral part of the modern general hospital, although many examples of the old division still persist. Tripier Hospital, a governmental hospital of the armed forces, in Hawaii, one of the most beautiful and modern of general hospitals, has its psychiatric ward more than an eighth of a mile from the main hospital building. Even university regents sometimes protest against including a psychiatric pavilion in a general medical center on a university campus.

In setting up the modern psychiatric unit we find in many places the same old prejudices, in a newer guise. Neurotic or psychosomatic patients are accepted but persons with more serious types of mental disorder are rejected. I know of no other branch of medicine in which only the mild cases are admitted to the general hospital and the more severe and serious are refused admission. What would be said of a surgical pavilion that took only the simplest surgical cases, or an obstetrical ward that took only simple and uncomplicated cases of childbirth? The psychiatric ward or pavilion of the general hospital should take all types of mental cases, just as the surgical pavilion accepts all types of surgical cases.

Obviously the psychiatric ward of a general hospital has many advantages for a mentally sick patient. Good consultation services from all other fields of medicine are available at a moment’s notice if only a corridor or door separates the medical from the psychiatric ward. Conversely, medical, surgical, obstetric, and pediatric cases can receive more accurate diagnosis and better care if psychiatric advice is as readily available as any other consultation. All patients can use the same laboratory, X-ray, electroencephalographic, and surgical facilities without need for costly duplication.

Finally, a psychiatric section within the general hospital makes not only the public but also medical and nursing students, and even doctors, think of psychiatry as simply one of the various fields of medicine. Teaching in psychiatry can be on a par with teaching in other specialties and thus make for an all-around preparation.

The specialized mental hospital will always be with us and will have its place, and we will always have specialized hospitals for the treatment of cancer, tuberculosis, and many other conditions. However, this specialization should never exclude the possibility that the general hospital will also have facilities for treating such conditions.

Preface

The outstanding failure of medicine has been in meeting the challenge of mental illness. The triumphs of modern medicine have been in the fields of internal medicine and surgery. In general, errors in medical practice have largely been due to ignoring the psychiatric approach to the patient’s problems. Ignorance and prejudice continue to dominate our thinking and to prevent our facing the extreme prevalence of mental illness.

The seriousness and wide extent of mental illness make it of concern to everyone. Yet only a few persons, in comparison to the magnitude of the task, have really come to grips with the nation’s most important medical problem—chronic mental illness. In past generations the mentally ill have been put away in asylums. The concept of mental illness which resulted in such treatment still persists; therefore the attempts to modernize state institutions and make them into real hospitals have only partly succeeded.

The great need is for complete integration of psychiatry within general medicine. Such integration can be accomplished only by getting general hospitals to accept their responsibility for treating mental illness without discrimination.

Men prominent in the practice and teaching of internal medicine were recently interrogated about their referral of patients to psychiatrists and their opinion of the effectiveness of such treatment. In their replies, these specialists almost unanimously agreed upon the great need for better integration of psychiatry into medicine. In part they attributed the present failure to the lack of psychiatric facilities in general hospitals, and stated that future advances in psychiatric medicine will depend upon improving the quality of psychiatric education in medical schools. They enlarged this statement to mean a closer working relationship between psychiatry and all the specialties of medicine in training interns, residents, and nurses, thereby providing complete medical care of both psyche and soma of all patients early in their illnesses.

Along with improved medical education must go a sound educational program based on community problems: programs for teaching health; research; knowledge of good mental hygiene principles; directions on how and where to obtain scientific help for people in emotional distress. Neglect of public education encourages the spread of cultism. At present far too many people go to cultists or quacks or are attracted by pseudoreligious promises.

Organizations like the National Association for Mental Health must take a greater interest in the problems of integration of psychiatry within general hospitals. The revision of obsolete commitment laws and the removal of all possible stigmas from the admission of the involuntary patient are basic. Recommendations by the American Hospital Association, by the President’s Commission on the Health Needs of the Nation, by the American Psychiatric Association, and by many interested agencies, should receive serious and careful consideration.

In the past quarter of a century my associates and I have done considerable pioneer work in developing four psychiatric departments within three general hospitals. As a result of the work and the experience thus gained, we began a general survey of the status of psychiatry within the general hospital field. This extensive survey, incorporated into a scientific exhibit and displayed at three national medical and two national hospital meetings, attracted much attention and brought inquiries from an increasingly large number of persons—psychiatrists, hospital administrators, and others. In order to answer queries and to provide at least partial information, we have prepared this book, based on the material that was collected for the exhibit.

This material was obtained by querying all registered hospitals classified as general by the American Medical Association and described by the American Hospital Association. Detailed questionnaires were sent to those United States and Canadian hospitals thought to have a psychiatric unit, and a short questionnaire was sent to all other general hospitals with more than 75 beds. A separate questionnaire was sent to medical schools.

We found, in the United States, 329 general hospitals with psychiatric beds, of which 279 had at least a 15-bed unit; of their 163,000 beds a total of 23,000 were for psychiatric patients. The other 50 hospitals offered beds merely for detention or temporary custody. In Canada, 21 general hospitals had such units, with 509 psychiatric beds in the total of 12,000 beds. Of the 950 United States general hospitals without psychiatric beds that gave information—although more than 300 occasionally accepted a psychiatric patient in an emergency or for diagnosis and very occasionally treated mild cases, and 400 reported some kind of mental hygiene clinic or psychiatric consultation—at least half offered no psychiatric service of any sort and never admitted a known psychiatric patient. Similar information came from 60 Canadian general hospitals. This means that although mental patients occupy more than half of all hospital beds in the United States and Canada, general hospitals accommodate less than 1 per cent of them. More than a third of the 73 four-year medical schools in the country do not have access, for teaching medical students, to a complete psychiatric unit in a general hospital.

The information and the many comments obtained from more than 1500 respondents, then, plus the experience we have had in setting up and conducting psychiatric units in several general hospitals, form the basis of this book, which aims to consider the main problems connected with installing and operating a psychiatric department within a general hospital. It is our belief that, as the advantages of the psychiatric unit are better understood, patients will gradually be admitted to general hospitals for treatment of acute mental illness to the same extent as for other acute medical illnesses, disorders, and accidents; that modern medicine will eventually accept its responsibility to treat the entire person. Thus, our book is, in part, devoted to advocating the use of general hospital psychiatry.

We have been fortunate to have the help of many associates, colleagues, and other friends interested in the general problem. Several have contributed chapters or parts of chapters, and others have aided in the preparation of certain sections. Those contributors who have written separate chapters or sections are listed in the table of contents and at the head of the appropriate section. In addition to these, various colleagues and other friends have aided in the preparation of the book by suggesting additions and revisions. Special help was given to us by the following persons: Howard O. Brower, staff assistant, and associates, Council of Medical Service, American Medical Association; Lewis Carpenter, Ph.D. and Christine Miller, Ph.D., clinical psychologists; Helen Byron of The Langley Porter Clinic; L. G. McKeever, M.D.; Frederick R. Ford, M.D.; June T. Eaton, R.N.; and Helen Jordan, R.N., O.T.R.

Generous and interested help came, also, from several medical students and secretaries: of the latter, Dorothy K. Clark was particularly helpful. We also wish to acknowledge with thanks the help of the various individuals and organizations that assisted us in gathering material for the survey. These were: Dr. Daniel Blain, Medical Director, American Psychiatric Association; Dr. Paul B. Magnuson, Chief Medical Director, Veterans’ Administration; Mr. C. C. Limburg, National Institute of Mental Health, United States Public Health Service; Dr. Harvey J. Tompkins, Chief, Psychiatry and Neurology Division, Veterans’ Administration; Dr. J. T. Boone, Medical Director (1952), Veterans’ Administration; Dr. W. B. Terhune, Committee on Cooperation with Lay Groups, American Psychiatric Association; American Hospital Association; National Association for Mental Health; The National Committee for Mental Hygiene, Canada; United States Public Health Service; and the mental hygiene departments of the various states and Canadian provinces. We are also grateful for the editorial assistance received from John Gildersleeve of the University of California Press.

We realize that our book, as a forerunner, has many shortcomings and gaps, but we hope that its publication may serve to stimulate others to enlarge, improve, and advance the scope of investigation and accomplishment in general hospital psychiatry. With greater and more concerted effort than in the past, the general medical and hospital administrative professions should be able, within the next decade, to meet the challenge of providing psychiatric care in the general hospital.

A.E.B.

Contents

Foreword

Introduction

Preface

Contents

CHAPTER 1 Staffing the Psychiatric Unit

THE NURSING STAFF

OCCUPATIONAL THERAPY

CLINICAL PSYCHOLOGY

SOCIAL SERVICE

CHAPTER 2 Training Programs

PHYSICIANS’ TRAINING

NURSING EDUCATION1

CHAPTER 3 Administration

CHAPTER 4 Architecture

CHAPTER 5 The Problem of Psychiatric Referral

CHAPTER 6 Medicolegal Aspects of Psychiatric Treatment

THE PSYCHIATRIST'S VIEWPOINT

THE LEGAL VIEWPOINT

CHAPTER 7 Voluntary Health Insurance and Nervous and Mental Disease

CHAPTER 8 The Day Hospital

CHAPTER 9 Special Treatments

DRUG THERAPY

ALCOHOLISM

GERIATRICS

GROUP PSYCHOTHERAPY IN GENERAL HOSPITALS

CHAPTER 10 Needs, Recommendations, and Suggestions for the Future

Index

CHAPTER 1

Staffing the Psychiatric Unit

Adequate and comfortable physical facilities are of course important, but they are secondary to a well-trained, qualified staff of psychiatrists, residents, interns, psychiatric nurses, occupational and recreational therapists, aides, and orderlies. A modern efficient department should also include psychologists and psychiatric social workers, at least on a part-time basis. A well-trained, closely knit, and cooperative staff can often compensate for a cramped, poorly arranged physical plant.

The unavailability of competent personnel is a major obstacle in the way of efficient operation of psychiatric departments. Indeed, a considerable number of psychiatric units that are physically ready are unable to function because of lack