Our 3rd 3 month rotation is at Howard State Hospital.
On a hill that rolls gradually up from the Pawtuxet River across Pontiac Avenue stands the Howard Reservation, a campus like setting that includes Victorian stone structures, numerous early twentieth century Colonial Revival brick buildings, and assorted new facilities. Its story is part of the social history of all of Rhode Island, not just Cranston. The development of Howard was Rhode Island’s first attempt to provide social services statewide through publicly supported and publicly administered institutions. As such, the Howard reservation signaled both a significant change in the role of the state and a major alteration in the treatment of the poor, the mentally ill, and the criminal.
Here is what, we student nurses experienced in 1969. Still in our junior year we leave our campus and move to what we call Howard State Hospital for our Psychiatric/Mental Health Nursing experience, where we lived on the premises for 3 months. The first night is creepy and scary. The patients that have ground privileges come around the building making weird sounds to frighten us. One of the students prize herself as a psychic, who can read us, through something that belonged to us, like jewelry, creating more anxiety around the unknown.
Sounds echo in the dorms, down the halls, and my laugh carried far. Before I know it I am called back to RIHSN to the Nursing School Director and told “You needed to keep it down”. I approached the topic of the Howard’s DON’s abuse of the patients and am told “You are not to get involved, not to report it or make a commotion about it, or you will be kicked out of nursing school”.
We investigate our surroundings, going into the basement; we come across cement tubs where they use to put the patients in ice baths and keep them in with canvas tops over the bathtubs. There are huge chains attached to large circular metal rings all up and down the walls, the energy of the place is one of water torture and inhumane practices, very dark and dungy.
The DON of Howard is our instructor and she is mean spirited. In our first class, she has one of the girls; sit in a chair in front of the class, then proceeded to unbutton her uniform almost to her waist before she stops, while the student sits quietly crying. The instructor yells at her for not stopping her. We all sat shocked and in disbelief at the treatment of our peer. Mimi and I would hitch-hike to the city and once we were picked up by the Police, who told us that our instructor had been arrested for stealing, that she was a kleptomaniac, warned us to watch out for her, and then they took us where we were going. Sometimes we go out in Norma’s old Studebaker car.
It is anxiety producing entering the locked ward we are assigned to. There is three levels of care here: 1) the patients with mild symptoms who are on open wards and can come and go to work, 2) our patients with severe mental illness, who are on locked units and are never let out and 3) the criminally insane who are violent and where students aren’t allowed. We walked down a long pathway with a wooden railing separating it from the sleeping quarters on the right that had rows of single beds in a long large dorm room. On the left side is a large open area which is the bathroom. At the end we come to 2 doors the left door leads to the nurses’ station and the main door leads to the Day room, it is a cold and uninviting space. The large day room is equipped with chairs along the 4 walls, tables and chairs in the center, and a couple of rocking chairs. The nurses’ station is enclosed, with windows looking into the dayroom and a small hole that medications are passed through to the patient, there is staff around making sure the meds are swallowed; using fingers to probe in mouths looking for pills, with those who have a history of cheeking them.
In the morning they are herded into the bathrooms made out of white tile with many drain holes for the water to pass into the sewers, white porcelain toilets and sinks and no place to hide or have any privacy. The staff is constantly yelling out what task to do, the patients act like robots: putting their pointing finger out while we place a strip of toothpaste on it and then they brushed their teeth with their finger. Without any clothes on they are forced to huddle together while taking cold showers with bars of soap, then they are allowed to dress, it is all so very humiliating my heart breaks for these poor souls.
Most of the patients have been here for many years, some have had lobotomies because of unmanageable behavior, they all appear chronically ill. They are not let outdoor and all meals are served in the dayroom with only a spoon for a utensil for no object is allowed that can be used as a weapon.
When it come to hair cut day there is a chair placed in the center of the room, while everyone else sits against the four walls watching, as everyone gets a bowl cut, if they did not go along with it they were sat on by the big charge nurse, straight out of “One Flew Over the Cuckoo’s Nest”.
The patients learned to love us for we are kind, considerate and interested in learning their story. Our last day on the unit, the staff are all lined up in the day room and the small mute woman patient goes up to the head nurse grabbed her by both nipples and twisted her down to the ground. Silently, I was cheering for the patient who had the courage to do such a thing, knowing full well that the consequences will be severe.
Psychiatric Nursing as a specialty is over 100 years old and has its roots in the Mental Health Reform Movement of the 19th Century which reorganized mental health asylums into hospital settings. Throughout the progress of this specialty, one skill that has created the foundation of psychiatric nursing is the one-to-one therapeutic relationship. It has been influenced by emergent psychotherapies and counseling skills has become an essential component in nursing education.
Hildegard Peplau developed the theoretical base for mental health nursing when she and others created the National League for Nursing in 1952 and suggested that all schools of nursing have a basic theory and practice course in psychiatric nursing. She firmly believed that the psychiatric nurse’s greatest tool was use of the self in the therapeutic relationship.
Psychiatric and mental health nursing concepts are present to us in all practice settings because the development of a one-to-one relationship is important in the creation of the patient’s trust in the caregiver. Assessment skills and communication are essential and taught in all areas of our nursing training in order to gather the information needed to make an accurate nursing diagnosis and subsequently treat the patient holistically.
We received experience and education in psychiatric nursing to provide care to an increasingly complex and seriously ill patient population through our ability to form one-to-one therapeutic relationships with the patients despite the environment we found ourselves in. Throughout history, psychiatric nurses lead the nursing profession in treating the after effects of war, disasters and the rising number of mentally ill individuals in society.
The therapeutic relationship is an abstract concept that can be defined as a planned and goal-directed communication process between a nurse and a patient for the purpose of providing care. We may counsel their patients but have not gone to counseling training. However, individual one-to-one work utilizing counseling skills is intrinsic to mental health nursing. Throughout our training we are developing observational skills, learning supportive approaches and sharing our education with patients. We are learning a non-judgmental attitude, we perceived inability to help our psychiatric patients, we feared mental illness and when studying our Abnormal Psychology book we identified with many symptoms, we had poor role models at the State Hospital and had a lack of support in clinical settings which were all deterrents to our development.
The history of Psychiatric practice in the first part of the 20th Century did not place much stake in particular diagnostic categories. The first official manual of the American Psychiatric Association, the Diagnostic and Statistical Manual of Mental Disorders (DSM-I, 1952) reflected the views of dynamic psychiatrists. Specific diagnostic entities had a limited role in the DSM-I and its successor, the DSM-II in 1968. These manuals conceived of symptoms as reflections of broad underlying dynamic conditions or as reactions to difficult life problems. Dynamic explanations posited that symptoms were symbolic manifestations that only became meaningful through exploring the personal history of each individual. It made little effort to provide elaborate classification schemes, because overt symptoms did not reveal disease entities but disguised underlying conflicts that could not be expressed directly. For example Schizophrenia is thought to be caused by the mother.
Karl Menninger, a leading dynamic psychiatrist, viewed all mental disorders “as reducible to one basic psychosocial process: the failure of the suffering individual to adapt to his or her environment…Adaptive failure can range from minor (neurotic) to major (psychotic) severity”. Rather than treating the systems of mental disorder, he urged psychiatrist to explain how the individual’s failure to adapt came about and it’s meaning to the patient thus almost everyone has some degree of mental illness at some point in their life. The focus of dynamic psychiatry broadened from the treatment of neuroses to more generalized maladaptive patterns of behavior, character and personal problems. Mental health patients came to be people who were dissatisfied with their relationships, careers, and their lives in general. Psychiatry had been transformed from a discipline that was concerned with insanity to one concerned with normality. This focus made the profession vulnerable to criticism that it was too subjective, medically unscientific, and overly ambitious in terms of its ability to explain and cure mental illness.
The following is taken from “1970 RI Historical Preservation Report for Cranston, Rhode Island”.
In summary for the first 150 years of American history, poverty, crime, and insanity were regarded as natural components of human society; the local approach to providing social services reflected the seventeenth and eighteenth century view of the town as the basic social organization. With the coming of the American Revolution and the nineteenth century, a new philosophy evolved. It held that deviance and poverty were not inevitable but simply the result of a poor environment. The solution was believed to be isolation of the poor, the mentally ill, and the criminal in an environment that eliminated the tensions and chaos engendering deviant behavior.
Poor farms and asylums sprang up around the country. In Providence, the Dexter Asylum opened in 1828 to care for the sick and feeble, and in the 1847, Butler Hospital was opened-one of the most progressive institutions for the treatment of the mentally ill in the nation. In 1839, Cranston’s Town Council voted to purchase the Rebecca Jencks estate in what is today Wayland Park at the foot of the present Meschanticut Valley Parkway, and use it as a poor farm.
Although by 1850 fifteen of Rhode Island’s thirty-one towns had established town asylums or poor farms, their operation did not reflect the kind of progressive thinking that was embodied at Dexter and Butler. The situation of the poor and the insane poor was not only scandalous, as revealed in Thomas Hazard’s 1851 “Report on the poor and Insane in Rhode Island”, which graphically delineated the miserable living conditions of most of the state’s poor, it also reflected a continuation of the local approach to social problems. Following Hazard’s report, the legislature abolished the chains and dark rooms that had characterized the treatment of the insane in many towns.
In 1866 a state Board of Charities and Corrections was established similar to that in Massachusetts, to “devise a better system of caring for the unfortunate unlawful classes of the state”. The act provided for the establishment of a state workhouse, a house of corrections, a state asylum for the incurable insane, and a state almshouse. The board moved to consolidate facilities by establishing a “state Farm” that would simultaneously raise standards for the indigent and relieve the localities of their responsibilities. Two adjacent Cranston farms were acquired the old Stukeley Westcott farm and the William A. Howard farm further west.
Plans for a state farm reflected the adoption by the state of Rhode Island of some of the current thinking affecting social services. The selection of a pastoral site far from the city is indicative of the prevailing philosophy that many of the nineteenth-century replaced assignment of the destitute to local families. Almshouses would care for the “worthy” or hard-core poor, the permanently disabled, and others who clearly could not care for themselves. The able-bodied or “unworthy” poor who sought public aid would be institutionalized in workhouses where their behavior could be controlled and where, away from the temptations of society, they would develop new habits of industry to prepare themselves for more productive lives and less dependency.
The creation of a state asylum for the insane signaled a significant change in public policy towards the mentally ill. Unlike the earlier optimistic era in the 1840s when Butler Hospital opened, the newer prevailing philosophy assumed that many of the insane were incurable, and therefore there was little justification for providing expensive hospitals for them. Thus in planning the State Asylum, therapy was the last of the goals listed. The Asylum would offer “every facility for economical, comfortable, and perhaps even to a degree, curative care…”
In 1885, to relieve the cities and towns from the burden of supporting their insane poor, the General Assembly adopted a resolution that the State Asylum for the Insane should serve as a receiving hospital for all types of mental disorder, acute as well as chronic, thereby merging the two. By giving over the Asylum to the “undesirable” elements, the poor, the incurable, and the foreign-born, the upper and middle classes thus restricted their own ability to use it. Therapy was second to custody.
The Board’s explanation for the rise in mental illness, agreed with the views of Dr. Edward Mann, Medical Supervisor of New York City’s Ward’s Island, who was quoted in the annual report for 1877:
“Next to hereditary pre-disposition, which is the first and predisposing cause of insanity, comes the great mental activity and strain upon the nervous system that appertains to the present age and state of civilization. This feverish haste and unrest, which characterize us as a people, and the want of proper recreation and sleep, tend to a rapid decay of the nervous system and to insanity as a necessary consequence.”
In 1888 funds for a new almshouse for the insane was obtained. The older wooden structure was replaced with the installation of a large central administration building with office and residential facilities for the staff and public eating and worship spaces for the inmates who were segregated in men and women wings flanking the central structure and a cottage for the children. It opened in 1890 the three and half story stone building stands as a series of long buildings running north-south and interrupted regularly by octagonal stair towers. Its handsome stone work and the red-brick trim and its site behind copper beach trees on a bluff overlooking Pontiac Avenue make the center Building one of the most visually striking structures in Rhode Island.
The major improvement of the decade before the turn of the century was the appointment of Howard’s first full-time superintendent, which signaled the introduction of professional training, therapy oriented administrators at the State Farm. The new orientation manifested itself in the building plan for the Hospital for the Insane created in 1900, based on the contemporary practice of constructing hospitals for the insane on the cottage or ward plan, “thereby establishing small communities in separate buildings that are more easily taken care of and administered,” the plan was the first at Howard to establish a campus like quadrangle arrangement of buildings in place of one large self-contained structure. A new key part of the new plan was a communal dining room constructed in 1903 with the room measuring 195 feet by 104 feet, which could seat 1,400 people.
In 1912, the reception Hospital (A Building) was opened, intended to permit appropriate diagnosis and classification of patients as they entered the institution. In 1916 psychiatric social workers were assigned to the state hospital. The training School for Nurses was opened in conjunction with the reception building. B Ward was completed in 1916 and C ward in 1918 completing the plan for “simple and dignified” buildings and “plain red brick walls with pitched roofs, without any attempt at ornamentation”. Standing just west of Howard Avenue and opposite the old House of Correction, the quadrangle signaled the beginning of a new mode of construction at Howard-red brick buildings in a simple Colonial Revival style grouped around a quadrangle and containing dormitories, single rooms, and porches as well as treatment facilities.
In 1918 a new building was constructed for the criminally insane and additional dormitories. The old twelve foot high solid fence which shut off patients from the outside world was replaced by a lower lattice one with view of the surrounding countryside. This change alone symbolized the change in attitude which was articulated in 1929 Annual Report:
“The commission tried to save dollars, but it would rather save a man or a woman. It wants to see plants in Cranston, Providence, and Exeter a credit to Rhode Island, standing like so many Temples of Reform, Education, and Philanthropy. But it is even more desirable that its work should be represented in reconstructed Living Temples in the morals, minds and bodies of those who have been ministered to by these public administrators. For it is better to minister than administer.”
These efforts at reform in treatment of the insane were paralleled by a new attitude towards the infirmed with attention focused on the medical, not the social, disabilities of the inmates. Rehab work program was started in 1928. Patients could live with families and work in the community. Most of the patients worked the 225 acres of state farmland, harvesting far in excess of the needs of the reservation. As late as 1941, 750,000 quarts of milk, 400,000 eggs and 14,000 tons of beef were being produced on the farm.
There is a long History of overcrowded and in 1933 the State Hospital, with accommodations for 1,550, housed 2,235 and was labeled the most overcrowded mental hospital in the northeast. In the years 1935-1938 twenty-five buildings were erected for the State Hospital for Mental Disease. The appearance of Howard was dramatically altered by this construction which went up so fast the Providence Journal declared a “new skyline rises at Howard.”
Built in a uniform, red brick, Georgian Revival style, the structures comprising the State Hospital and State Infirmary are grouped in campus fashion on either side of Howard Avenue. Taken in total, the building incorporated a uniformity of style, scale, material, and sitting that is striking. Historically they represent the coming together of national policy and local initiative. Architecturally, they present one of the most lucid statements of the Georgian Revival in Rhode Island. Despite the improvements by 1947 conditions once again deteriorated due to overcrowding. In 1959 an expert from Boston declared the conditions were shameful and yet “relatively good” compared with mental hospitals in the country, due to the inability to raise capital funds to match federal programs. In 1954 there was an active public-relations effort, including pamphlets detailing the overcrowding, articles in the Journal, and radio spots resulted in passage of a bond issue. In 1962 the General Hospital and the State Hospital for Mental Diseases merged to become the Rhode Island Medical Center. The former became the Center General Hospital and the latter the Institute of Mental Health. In so doing, Rhode Island was the first state to create therapy units for its mentally ill. In 1967, the Medical Center was divided. The Center General Hospital was designated to serve as an infirmary for the prison and the Institute of Mental Health.