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Kirkbride’s Architectural Stigma of Mental Illness
In the middle nineteenth century, Dr. Thomas Kirkbride was the preeminent medical doctor in asylum medicine as well as the leading authority on the design of mental asylums in America. His book, On the Construction, Organization, and General Arrangements of Hospitals for the Insane, described Kirkbride’s ideal mental hospital. He believed that psychiatric hospitals should be secluded from cities and built on a linear floor plan to maximize their therapeutic benefit. Based on this design, huge hospitals mysteriously secluded from population centers were built during the late 1800s as the prevalence of mental illness grew in America. These hospitals accommodated patients for over a century despite overcrowding, underfunding, and stories of patient abuse. Many of these Kirkbride hospitals which held much hope for healing still stand today as reminders of the difficulties of treating chronic mental illness.
They loom on the outskirts of towns across the United States. Their imposing facades mask inspirational stories of recovery and horrific accounts of abuse. These buildings constructed in the nineteenth century were called insane asylums, and they remind us of a time when psychiatrists thought architecture could treat mental illness. They became known as state mental hospitals in the early twentieth century, and many of these structures still stand today. Although most are no longer used as hospitals, a few continue to house patients with chronic psychiatric conditions who have no other place to live. Some of these grand structures have been converted to government office buildings, condominiums, and even haunted houses complete with paid tours.
One man’s design greatly influenced the construction of these massive buildings in the nineteenth century. Dr. Thomas Kirkbride worked as a psychiatrist at the Pennsylvania State Hospital for most of his professional career. As a young doctor, he developed an interest in architecture and its supposed curative effects on mental illness. This led him to write his own guide on how asylums should be built. On the Construction, Organization, and General Arrangements of Hospitals for the Insane was published in 1854 with the second edition following in 1880 (Yanni, 2007, p. 59).
Two prominent features of the design Kirkbride proposed for asylums were the secluded setting and linear floor plan arrangement. Kirkbride (1880, p. 26) believed that proper treatment of the mentally ill involved removing them from their turbulent lives at home and in society. He felt that a secluded, rural setting away from the city would provide a more therapeutic environment. At the same time, he was keenly aware of the financial costs of treating mental illness and promoted the linear plan to be the most cost-effective design for a mental hospital. Buildings constructed in the linear plan had setback wards stretching out from two opposite sides of a large central administration building. Although this design created massive buildings, the growing demand for more hospital space quickly outpaced the supply. Most state asylums quickly became overcrowded and understaffed. They were built with the best intentions of healing, but these asylums eventually only provided custodial support for patients instead of true mental health care (‘Kirkbride Plan,’ 1976). For well into the twentieth century, these mental hospitals continued to act as ‘dumping grounds for individuals outside the pale of normal society’ (Grob, 1994, p. 245). Kirkbride did not intend for his hospitals to become warehouses for the untreatable. He thought these hospitals would help patients regain their health and self control through structured living and soothing surroundings. Armed with their rediscovered sanity, they would ideally return to the community as productive citizens after a brief hospitalization. But many patients did not recover and spent years in these grand buildings as chronic victims of a neglected system.
These impressive hospitals mark the successes and failures of psychiatric treatment. They cannot be separated from the history of abuse and the public mystery surrounding what transpired within their walls. This paper will explore key architectural aspects of Kirkbride’s design that have reinforced his hospitals as symbols of chronic mental illness.
Moral Treatment and the Father of the American Asylum
Thomas Kirkbride was formulating his theories on the causes and treatments for mental illnesses well before he earned the reputation as the most notable asylum doctor in the nation. In medical school, Kirkbride learned a therapeutic style directed towards letting the body heal itself without the intervention of potent drugs (Tomes, 1994, p. 59). His religious affiliation as Quaker also placed him in a category with earlier Quaker mental health specialists: William Tuke and his son—Samuel Tuke. William Tuke developed the York Retreat in Great Britain as an asylum farm dedicated to moral treatment after reportedly learning of a Quaker girl who died there because of abusive treatment (Edginton, 2007, p. 85). Tuke emphasized moral treatment as a therapeutic regimen of regular work and a supportive environment, in addition to appealing to reason as a means of evoking normal behavior with minimal pharmaceutical intervention (Tuke, 1813, p. 133-135). In Samuel Tuke’s Description of the Retreat in 1813, he upholds his father’s belief that the Retreat’s disciplined yet soothing and homelike environment could heal madness (Edginton, 2007, p. 100). Philippe Pinel, a French physician, was simultaneously promoting the humane treatment of the mentally ill in Paris. While working separately in their respective countries, Tuke and Pinel were widely credited as the first advocates encouraging the benevolent treatment of patients with mental illness over the previous punitive treatment. Thomas Kirkbride recognized the role of Tuke and Pinel and credited both for improving the prospects of treating mental illness (Grob, 1994, p. 29). He would soon become the advocate for these ideals in the United States, combining the concepts of moral treatment and healing architecture into a cohesive asylum design.
Description of the Retreat in 1813 presents two elements of design later to be incorporated by Thomas Kirkbride into his own asylum plan: relative seclusion from cities and a main building with linear wards. Tuke (1813, p. 93) explains that the Retreat was built on a hill about a half mile from the city of York, and from the grounds, one can see the beautiful wooded country for nearly 25 miles. Tuke likely saw this beautiful setting as conducive to healing, but the Retreat also required seclusion and plenty of surrounding land in order to function as a viable farm. Also, implicit in the basics of early moral treatment, if mental illness resulted from the strenuous hardships of society, then the mentally ill must be isolated from that society in order to be healed.
In addition to the seclusion of the asylum farm, Description of the Retreat features a linear floor plan of the main dwelling. A central hall bisects individual bedrooms running down the length of the main house (Tuke, 1813, p. 100). On each end of the main house, a smaller ward is set back from the facade of the main building as to create a simple V pattern in an aerial view. This arrangement provides separation between groups of patients while keeping the entire complex connected. Thomas Kirkbride would soon expound upon this element of design in his guide to building what came to be the most impressive asylums to date.
Writing the book on American asylums
As a young doctor in training, Kirkbride worked with psychiatric patients at the Pennsylvania Hospital—a medical hospital in Philadelphia. The psychiatric ward was housed in the West Wing of the hospital, and many visitors flocked to the West Wing to see the mentally-ill patients to satisfy their curiosity (Tomes, 1994, p. 34). As the West Wing became overcrowded with more patients and unwanted visitors, a new hospital was soon planned to specifically treat mental illness. Kirkbride accepted a prominent job in planning and managing the new Pennsylvania Hospital for the Insane. The new hospital would be located outside the city for the purpose of ‘adequate isolation, (and) ample room for new buildings and recreation areas’ (Tomes, 1994, p. 35). Kirkbride would design the new hospital and work as the chief physician and superintendent for the remainder of his career (U.S. National Library of Medicine, accessed 2009). He would also write his treatise on asylum construction while working at the Pennsylvania Hospital for the Insane.
On the Construction, Organization, and General Arrangements of Hospitals for the Insane served as a comprehensive guide to architects and state governments on how to construct proper mental hospitals. In the book, Kirkbride explicitly discusses every detail of the asylum, from the ideal dimensions of windows to the best types of flooring materials. It was the most complete publication on the design of institutional housing for the mentally ill to date. As a result, most of the state asylums built in the latter half of the nineteenth century borrowed from Kirkbride’s design in their construction.
Kirkbride himself felt that 80 percent of mental illness could be cured, provided that it was treated in the proper setting and early in the course of the disease (1880, p. 23). He promoted the construction of state-funded asylums in every state of the country in order to give prompt care to the curable patients and ‘comfort to those that (were) not curable’ (p. 26). The secluded hospital setting offered the best therapeutic environment according to Kirkbride. He believed that psychiatric wards should not be attached to ordinary medical hospitals for fear of intrusion and eventual degeneration (p. 28). With proper seclusion in a peaceful setting, patients would be given the optimal environment in which to heal. In fact, Kirkbride explicitly wrote that asylums ‘should always be located in the country, not within less than two miles of a town of considerable size’ (p. 37). Kirkbride recognized the need to keep the public out while also protecting the community from potentially dangerous patients (p. 26). Creating a healing environment that simultaneously confined a disturbed segment of society was a particularly ambitious venture, but Kirkbride believed a majority of mentally-disturbed patients would recover with treatment in agreeable surroundings.
A major consideration in building a good asylum included providing access to fresh air and adequate light. Kirkbride regarded the linear plan of wards originating from a central building to be the most cost-effective way of ensuring good ventilation and light exposure. The floor plan extended out from the central building in two opposite directions in a series of wards; each ward was set farther back than the previous. This plan resulted in a large building with ‘connected pavilions arranged in a shallow V’ when viewed from above (Yanni, 2007, p. 51). In addition to supplying air and light, the linear plan could also separate patients by wards based on varying severities of mental illness. Violent and loud patients could be placed in the wards farthest from the central administration building to prevent disturbing other patients and their visitors (Kirkbride, 1880, p. 138). Despite its obvious strengths, the linear plan required a large plot of land to build. However, this did not trouble Kirkbride, since he already felt it necessary to build the asylums on secluded acreage for the tranquility of the patients.
Incorporating proper ventilation and light also became a focus in the design of nineteenth-century medical hospitals to prevent the spread of infectious diseases. Florence Nightengale was also integrating ventilation and light in her own design of the ideal medical hospital. She published Notes on Hospitals in 1863. Like Kirkbride, Nightengale thought that hospitals should be built outside city centers in ‘pure air’ (1863, p. 26-7). She also believed in separate pavilions. However, Nightengale attempted to maximize ventilation and light while limiting the expanse of the hospital. Smaller hospitals could be built in a simple linear plan, but instead of placing new wards out from the center as the need for rooms grew, Nightengale’s plan added pavilions perpendicularly to the central building in an H pattern (p. 94). Hospitals built on this plan ensured sufficient fresh air and light and required less land to build. Nightengale’s ideal medical hospital could also easily be built closer to city centers than Kirkbride’s asylum, making these facilities quickly accessible to the public. However, seclusion was a key element of Kirkbride’s treatment of mental illness, and the asylums built on his design ended up as large, reclusive monuments for the treatment of chronic patients who often did not respond favorably to available therapies.
The Growing Asylum
Through the middle nineteenth century, Thomas Kirkbride became the most prominent psychiatrist in the country on the topic of architecture (Yanni, 2007, p. 38). His role as a key member in the Association of Medical Superintendents of American Institutions for the Insane ensured that his asylum design would become the model on which many state psychiatric hospitals were built. As Kirkbride’s authority was rising nationally, the United States was advancing socially and industrially. The psychiatric field linked mental illness to the emerging stressors of this changing society, and because society was thought to cause the problem, it was the responsibility of society to fix the problem (Rothman, 1971, p. 125, 129). New industrial development meant increases in crime, unemployment, and other social hardships leading to a higher prevalence of mental illnesses (Grob, 1994, p. 40). The secluded asylum would be the monumental symbol of the confidence of psychiatry in treating the burgeoning mental illnesses of a new and prosperous country.
As the country grew, the need for more asylums grew accordingly. In The Art of Asylum-Keeping: Thomas Story Kirkbride and the Origins of American Psychiatry, Nancy Tomes reports that the number of mental hospitals increased from 18 to 139 from 1840 to 1880 (1994, p. 265). Typically, families cared for their own mentally-ill members in the home, but when those patients became too difficult to handle, they had the asylum as a final option (Tomes, 1994, p. 103). Most patients entering asylums in this era were admitted by their families. Even with the dramatic increase in the number of asylums built, overcrowding quickly became a problem. To accommodate the need, the Association of Medical Superintendents of American Institutions for the Insane increased its guidelines for the average capacity of 250 patients per asylum to 600 (Tomes, 1994, p. 286). Many facilities soon surpassed the new limit of 600 patients. This high demand for psychiatric care supported claims that the prevalence of psychiatric illness was increasing, and these patients could not be adequately cared for in the home. However, sick patients were entering the asylums quicker than recovered patients could leave.
Kirkbride’s initial assessment that 80 percent of patients could be cured proved to be overly optimistic. Nancy Tomes writes that only 47 percent of Kirkbride’s patients completed his treatment plan (1994, p. 222). Most patients were not being definitively cured in one hospitalization. The patients who showed no improvement remained in the asylum while new patients continued to be admitted. Nearly every hospital began to accumulate ‘patients who did not recover’ (‘Kirkbride Plan,’ 1976, p. 476). The chronic patients continued living in the same Kirkbride buildings for many years. As the need grew, newer and bigger institutions continued being built with grander facades to instill more public confidence in the asylum’s role in curing mental illness.
Buffalo State Hospital was perhaps the grandest of these asylums based on Kirkbride’s linear plan. Legendary architect H.H. Richardson designed the hospital using Kirkbride’s general framework for asylums. Upon completion in 1895, the massive complex measured approximately 2,200 feet long (Yanni, 2007, p. 129). Five connected pavilions projected from the east side with five identical wards extending from the west side of the central building (Figure 1). Two copper-coated spires rose from the central building in Richardson’s Romanesque style creating a mysterious building that often instilled fear rather than tranquility and peace of mind. Albert Deutsch wrote Shame of the States in 1948 in an effort to publicize the deteriorating conditions in American mental institutions. Although he does not refer directly to Buffalo State Hospital, he likely had Buffalo in mind when he described New York’s large psychiatric hospitals as ‘monumental monasteries of the mad’ (Deutsch, 1948, p. 136). Buffalo, like all other state institutions in the late nineteenth century, had its share of patients who did not respond to treatment and stayed in the hospital for extended periods of time. This long-term trend of institutionalization marked the beginning of a subculture of chronic mental patients housed in large, ominous state facilities. An architectural stigma of mental illness evolved as an unintended consequence. As chronic patients continued to live in hospitals like Buffalo throughout the twentieth century, this architectural stigma furthered exacerbated the general alienation of patients with mental illness.
Alienation and Seclusion
Through the twentieth century, state asylums came to be seen as neglected holding grounds for the incurable. Lawmakers allocated less funding to mental health as the hope of new treatments grew stale. From the viewpoint of social control, the asylum was ‘a useful place for locking up lunatics’ (Rothman, 1971, p. 239). Patients lived in neglected and overcrowded conditions while the Kirkbride buildings housing them crumbled.
In The Mad Among Us: A History of the Care of America’s Mentally Ill, Gerald Grob notes that as public funding decreased and the large asylums became overcrowded and run-down, the superintendents of these institutions found it even more difficult to shape the environment into a therapeutic one (1994, p. 82). Conditions became so bad that infractions upon basic human rights became common. About 30 states had laws requiring ‘mandatory sterilization of confirmed criminals, idiots, imbeciles, and rapists,’ and nearly 18,500 mentally-ill patients in public hospitals were sterilized surgically between 1907 and 1940 (Grob, 1994, p. 161). Those suffering mental illness were equated to criminals, and the Kirkbride buildings came to be seen as penal institutions instead of hospitals. To make matters even less favorable, many families were unable or unwilling to take their institutionalized family members back when they were finally discharged from the hospital. Oftentimes, the patients leaving the psychiatric hospital had no family left in the community, and the longer the patients stayed in the hospital, the less likely they were able to survive outside it. The advent of new medications to control psychotic disorders in the 1940s and 1950s and the movement towards outpatient community care in the 1960s did not prevent many patients from returning to the state hospital. As Grob points out, the plan to provide proper outpatient care of the mentally ill in the community assumed that these patients had supportive families and homes outside the hospital (1994, p. 168). Often, this was not the case. Therefore, unprepared for a successful life in the community, the state psychiatric hospital became their only housing option. Between 1955 and 1970, while the population of patients in state hospitals decreased by nearly 40 percent, the number of admissions more than doubled (Grob, 1994, p. 258). This evidence supports more chronically-ill patients being readmitted to the hospital because of a lack of social support in the community. Further lack of government funding in the 1980s led to the treatment of most acute psychiatric patients in general hospitals, but state psychiatric hospitals ‘remained the largest provider of total inpatients days of psychiatric care’ (Grob, 1994, p. 291). Summarily, chronic patients in the later twentieth century whose illnesses did not respond to treatment often remained in the same deteriorating Kirkbride buildings that had been used for over a century. Long-term separation from the community grouped these individuals into a subculture of chronic mental patients and stigmatized them based on their illnesses and living conditions.
Because of this group isolation, the chronic patients faced an institutional stigma from the public upon leaving the hospital. Once confined in the massive state hospital whose imposing character approximated a Gothic prison, society considered them to be different (Goffman, 1961, p. 355). Their stay in the hospital was much longer than a typical medical hospitalization. The public saw something very wrong with them to have spent such an extended time in such a mysterious and secluded place. After stories of abuse grew throughout the first half of the twentieth century, the asylum became an even more chaotic and unorganized environment. The hospital was supposed to be a place where a sick person could go in hopes of recovering and leaving. These hospitals were to be transitional facilities, but due to poor conditions, the public saw instability. Mary Douglas in Purity and Danger describes transitional states (e.g., the asylum) as ‘indefinable’ and the person who passes between them (the patient) is not only in danger but also ‘emanates danger to others’ (1966, p. 96). Kirkbride’s original plan of proper treatment included secluding patients from the societal stressors which he believed worsened their disorders. Providing this seclusion no doubt avoided social tension between the public and the mentally ill while also reinforcing new tensions (Evans, 1978, p. 20). Transitioning back into the community became a greater challenge. The best a person could do after leaving the state hospital was to try to blend into the community, hope that no one knew of their past, and trust that their illness would not recur at an inopportune moment.
A stigma remains tied to mental illness which extends to the mysterious Kirkbride buildings in which many suffering patients were confined (Yanni, 2007, p. 151). These buildings represent a time in American history where the arrogance of the psychiatric community helped construct colossal asylums to overcompensate for a lack of effective cures. What remain today are enigmatic monuments shrouded in mystery which inspire the imaginations of viewers.
The Public and the Haunted Asylum
Searching for asylums influenced by Thomas Kirkbride on the internet reveals numerous websites dedicated to the appreciation of these awesome buildings. People across the country use message boards on these websites to post pictures of the Kirkbride buildings in their communities. While perusing these message boards, one can quickly find entries about rumors of ghost stories at many of these mysterious facilities. Writers post entries theorizing about the mistreatment that took place behind locked doors. Dr. Kirkbride’s grand hospitals have become mysterious symbols of illnesses that the public fears. Instead of trying to understand what caused the deteriorating environment of the treatment of mental illness, the public has become inclined to see the buildings themselves as prisons that hold secrets to why abuse and neglect occurred. The dark and gloomy hospital exteriors make the tendency to preserve ghost stories even easier. The entertainment of imagining that these buildings are haunted, however, further alienates the patients who were hospitalized in these buildings. In fact, perpetuating these ghost stories often borders on exploitation of the former patients.
Weston State Hospital in West Virginia often frightens visitors with its tales of abuse. Private owners bought Weston State Hospital in 2007 and quickly reverted back to using an older name for the building: Trans-Allegheny Lunatic Asylum (Legg, 2008, p. 08). The company website highlights paid ghost tours of the building throughout the year, and the tours frequently sell out near Halloween (Trans-Allegheny, 2009). In time, citizens who live near Weston State Hospital will have a greater chance of knowing this building as a haunted house than as a building inspired by Dr. Kirkbride, who honestly hoped for the recovery of its patients.
Danvers State Hospital in Massachusetts holds a notorious reputation as a Kirkbride asylum where mistreatment and overcrowding were common in the late nineteenth century. When Danvers was built, the public was ‘wary of the hospital’s neo-gothic architecture and mindful of its location near a site central to the Salem Witch Trial’ (DeLancey, 2009, p. 1). These superstitious elements made the local citizens more likely to believe the realistic accusations of abuse. The hospital ceased inpatient hospitalizations in 1992, and its abandonment only intensified the legend of Danvers. A recent horror movie was even filmed at the hospital, further strengthening the general belief that bad things happen at Danvers (DeLancey, 2009, p. 2).
An internet message board discussing Buffalo State Hospital echoes many similar public sentiments. The main hospital sits empty, and like Danvers, its abandonment has added to the suspense surrounding the building. One contributor to the website wonders why old asylums were built to look like ‘Gothic structures and castles,’ but then quickly adds that this makes for ‘good ghost stories’ (‘Dark Asylum,’ 1 January 2006). Other writers on this message board tell of their fear of the building since childhood and describe getting chills when passing by (‘Dark Asylum,’ 10 January 2006, 12 May 2006). These contributors are directly referencing the modern architectural stigma of Kirkbride hospitals. It is reasonable to conclude that citizens living near Buffalo State Hospital would consider patients once confined in this building to be different from average citizens.
In 1948, Albert Deutsch proposed that the ideal state mental hospital should look like a hospital and not a prison (1948, p. 183). Unfortunately, because of insufficient public funding, many chronic patients would continue to live for decades in the same secluded Kirkbride hospitals that Deutsch criticized. Perhaps the greatest lesson learned from Dr. Kirkbride was not that secluded hospitals with plenty of fresh air and good scenery could cure illness, but that ideals cannot be realized without practical applications and consistent public support. Perhaps the goals of the asylum were ‘so grand that some disappointment was inevitable’ (Rothman, 1971, p. 237).
Although Kirkbride has been remembered as a pioneer of moral treatment, the perception of his buildings has evolved in the past 150 years. They were meant to project a sense of civic pride and generosity, but they were too ornate and wasteful (Yanni, 2007, p. 1, 151). As these hospitals collected chronic patients throughout the twentieth century, they began to be viewed as hopeless prisons. Now, they sit largely abandoned as ‘grim reminders of an often inhumane system’ (p. 1, 151). The public is filled with questions about these mysterious buildings and the patients who lived in them. In trying to answer these questions, the buildings themselves become more intriguing because they still exist as part of local communities. They tower over the landscape ominously and offer no explanations as to what occurred within their walls.
One of the truly lamentable misconceptions of Dr. Kirkbride’s design was the excessive decoration added by individual architects responsible for the actual construction of each hospital. Kirkbride (1880) said that the architecture should impress the patients and their visitors without being elaborate, and the hospital should have a ‘comfortable and cheerful appearance’ (p. 52). The architect’s desire to put their own style into the hospital culminated in the ornate exteriors that presented an arrogant attitude to the public. The architects’ exterior details can be seen as excessive interpretations of what was needed to impress the public. While these extravagancies cannot be explicitly attributed to Kirkbride’s design, they cannot be divorced from it either.
Kirkbride designed his hospitals to house 250 patients and to be expandable to accommodate up to 600 if the need arose. He felt that 250 was the ideal number based on how many patients could be seen by the doctors in one day (Kirkbride, 1880, p. 50). It was not long before most hospitals housed at least five times this many patients, and the hope of moral treatment gave way to overcrowded custodial care.
As the need for more hospital space increased, gigantic V-shaped hospitals were designed by adding more staggered wings to the exterior wards. The massive, secluded hospitals alienated the patients and separated them from their communities physically and ideologically (Moran, 2007, p. 165). This made their transition back into social life more difficult. One wonders if psychiatric hospitals would have been more socially-accepted and effective in treatment if they were based on Florence Nightengale’s pavilion plan and located closer to civilization.
While Dr. Kirkbride’s buildings have been criticized, his dedication to helping patients cannot be overstated. He recognized that mental illness should be treated as any other illness, and its sufferers deserve respect and kind regard. Many of the dilemmas Kirkbride faced remain unsolved today. The United States Joint Commission on Mental Illness and Health noted in 1961 that the public views mental illness with less sympathy than physical illness (1961, p. xviii). Over 40 years later, the President’s Executive Summary of 2003 points out that the stigma of mental illness continues into the twenty-first century (United States President’s New Freedom Commission on Mental Health Executive Summary, 2003, p. 7) This continuing problem facing mental illness should not be construed as a total lack of national progress in treating these disorders. Rather it shows how persistent the problem of mental illness can be. In the spirit of Dr. Kirkbride, stigma will fade and treatments will improve as long as the motivation to cure these illnesses remains strong.
The author wishes to thank Dr. Chris Crenner at the University of Kansas School of Medicine for his continued support and guidance in this research, Dr. Carla Yanni at Rutgers University for her valuable advice, and Diane Richardson at the Oskar Diethelm Library at Weill Cornell Medical College for her research assistance. Finally, special thanks to Chad Bristow for his architectural expertise and advice.
Figure 1. Overhead plan of Buffalo State Hospital showing an expanded linear floor plan with setback wards originating from a central building to create a large V-shape. From American Journal of Insanity, July 1872, 29, 6-7. Courtesy of Oskar Diethelm Library, History of Psychiatry, Weill Cornell Medical College.
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Copyright Priory Lodge Education Limited 2009
First Published November 2009