From Asylum to Community: Mental Health Policy in Modern America

by Gerald N. Grob

The distinguished historian of medicine Gerald Grob analyzes the post-World War II policy shift that moved many severely mentally ill patients from large state hospitals to nursing homes, families, and subsidized hotel rooms--and also, most disastrously, to the streets. On the eve of the war, public mental hospitals were the chief element in the American mental health system. Responsible for providing both treatment and care and supported by major portions of state budgets, they employed more than two-thirds of the members of the American Psychiatric Association and cared for nearly 98 percent of all institutionalized patients. This study shows how the consensus for such a program vanished, creating social problems that tragically intensified the sometimes unavoidable devastation of mental illness. Examining changes in mental health care between 1940 and 1970, Grob shows that community psychiatric and psychological services grew rapidly, while new treatments enabled many patients to lead normal lives. Acute services for the severely ill were expanded, and public hospitals, relieved of caring for large numbers of chronic or aged patients, developed into more active treatment centers. But since the main goal of the new policies was to serve a broad population, many of the most seriously ill were set adrift without even the basic necessities of life. By revealing the sources of the euphemistically designated policy of "community care," Grob points to sorely needed alternatives.

Originally published in 1991.

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430 pages, Hardcover

First published January 1, 1991

About the author

The son of Jewish immigrants from Poland, Gerald Grob earned a bachelor's degree from the City College of New York and a master's degree from Columbia University. He earned his doctorate at Northwestern University in 1958 and taught at Clark University from 1957 until 1969 and at Rutgers University from 1969 until his retirement in 2000.

Reviews

[Durakov · Rating 3 out of 5]

The picture inserts in the center of the book give one a pretty good idea of Grob's approach: there's one picture of a line of beds, three pictures of patients standing around doing nothing, one picture of a patient strapped to a bed, two pictures of people actually working in the field, an aerial shot of a building, one picture from a movie, and ten pictures of mostly front-facing men in suits. This story is of course about policy, specifically the shift from a focus on intra-hospital policy to extra-hospital policy, and that story does involve a lot of men in suits signing pieces of paper. But policy is not just some words or the result of applying the findings of a commission. Patients are involved at every single step, but they are completely silent here. They exist as mass statistics, demographically subdivided somewhat by class and severity of illness (perhaps a few times by gender, but never by race). Patients are the mute and immobile recipients and objects of policy. None of these policies could have been implemented without massive amounts of labor, but labor is also silent (except for the most highly specialized positions). Nursing assistants, hospital attendants, and similar positions spend the vast majority of time with the actual patients and being in the institutions discussed, but here they get nothing except the same generic demographic treatment as an interest-less and voice-less mass being directed this way and that.

It's true that Grob is basically indispensable. His three-volume trilogy on mental health policy in the US is a must-use resource. But it's best used as a source-book. In Grob's view (never stated so directly but clear by how he fills his pages), mental health policy is the result of Big Ideas from Important Men. He comes off as something of a weirdly cynical incrementalist: a true pessimist centrist. He claims changes in the field are "evolutionary" (but then highlights the cyclical nature of reform). He casts aspersions on all reform and is quick to point out shortcomings, but he's not exactly a cheerleader for the dominant approaches, especially when they militate in any way. Hospitals were bad and so were reforms. Ok, we can agree on that. The professionals have failed in their stated mission at virtually every step. But since Grob's conservatism and pessimism prevents him from considering the depth of the field's dependency on economic and political condition, because his abiding faith that all change comes from incremental deviations along a basically straight line, because there is an implicit argument that the deeper "whys" are eternally elusive, he implicitly seems to hold that the only thing you can do is have faith in the professionals regardless.

It's a highly flawed history, not exciting in the least, and one still deeply indebted to a kind of Great Man of History approach (where here the Great Men are sniveling bureaucrats among whom more mild conservatives who discover that the social world exists are treated as if they were Bolsheviks in white coats), but the trilogy as a whole is undeniably a thorough resource and still 100x better than Edward Shorter's abysmal history of psychiatry.

[Claire · Rating 4 out of 5]

This is one of the most thorough and carefully researched historical works I have ever read. While it was quite dry in many areas, this is to be expected for a work focused on policy, and Grob writes in a way that is engaging enough to keep my interest. I thought the structure was a bit confusing, as multiple chapters will cover the exact same era from a slightly different perspective, so it was at times a bit difficult to get the whole picture of how things were at the time. That being said, I do understand that a purely chronological, and thus all-encompassing approach would have had its problems as well. Mostly, I appreciated that Grob took such an objective stance on mental illness. His opinion comes out somewhat in his tone while writing about antipsychiatry, but he had nowhere near as much vitriol as other scholars on this topic, and he made a strong effort to focus his criticisms on objective facts and statistics. Reading about everyone's hot take on mental illness genuinely gets exhausting when you research it as closely as I do, so I really did appreciate a text so heavily focused on historical information rather than the author's own opinions.