With increasing populations, the recovery rates reported by state institutions became suspect. While Dr. Kirkbride was acclaimed for his successful treatment rate, he led a private hospital where he could more directly influence outcomes. The typical state hospital superintendent oversaw many more patients and staff and had broader administrative duties. Even those superintendents considered humane and ethically principled were exposed to belligerent and litigious patients and politically-motivated government scrutiny. In the 1880s, Pliny Earle, Kirkbride’s longtime colleague and also a Quaker, expressed the growing pessimism of superintendents, openly challenging AMSAII’s claims about the curability of mental illness. Earle published a series of research articles that revealed with crystalline precision how the data produced for annual reports had falsely inflated treatment rates. While such practices assuaged taxpayers and government officials in the short term, misrepresenting the effectiveness of mental health at state facilities led to serious complications.
Psychiatric hospitals became catch-alls for a broad range of misunderstood neuroses, developmental disabilities, neurological diseases and disorders, communicable diseases, modes of depression, and “aberrant behaviors.” With rising patient numbers and diminishing state support, conscientious care devolved into custodial management, and many people spent the remainder of their lives at state facilities. Hospitals that had been designed to return patients to the world were now filled with chronic residents, often involuntarily confined. With astonishing ease and convenience, patients were committed by their own family members, then abandoned. Elder siblings committed younger siblings over family inheritances. Husbands committed wives who suffered from what we recognize today as postpartum depression, placing their children in foster care, only to remarry within a year. Wives committed themselves to avoid spousal abuse. Such behaviors compounded larger systemic failures and human rights abuses. Tales of mismanagement, misdiagnosis, and sinister malpractice proliferated.
During the first half of the 20th century, the majority of American psychiatric hospitals, including Kirkbrides, devolved into frightening dystopias, offering cautionary reminders of the frailties of social infrastructures, scientific hubris, and the dire consequences of depersonalizing bureaucratization. Increasingly invasive and unethical treatments with questionable medical value replaced respectful care, producing results that were at best inconclusive, and at worst permanently disabling and even deadly. Such procedures included insulin shock and chemical shock in the 1920s and 30s, prefrontal and transorbital lobotomies in the 1930s and 40s, chemical lobotomy beginning in the 1950s, and a eugenics program, involving forced sterilization of the mentally ill, that began at the turn of the 20th century and continued until 1981.
Almost a century after Dr. Kirkbride first embraced photography in his Magic Lantern Therapy, Quaker activists used photography to expose the widespread mistreatment of mentally ill patients in hospitals their ancestors had helped create. During World War II, 3,000 conscientious objectors (Quakers, Mennonites, and Anabaptists) had been assigned to 62 mental hospitals across the United States. In May 1946, Life Magazine published photographs covertly taken by Charles Lord, a Quaker, showing the deplorable conditions at Byberry State Hospital in Philadelphia. Following so soon after the Allies’ military victory, the shocking images carried overtones of the concentration camps in Nazi Germany, puncturing the sense of American superiority and planting seeds for deinstitutionalizing mental health care.