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SECOND
EDITION SECOND EDITION
W
hen it was originally published in 2009, the Textbook of Hospital Psy-
chiatry was the first comprehensive guide to hit the market in more
than a decade. This updated edition includes new material in each of
the chapters, with a focus on treatment, staffing, and quality-of-care changes, and
offers new, forward-looking chapters on consumer and family perspectives, col-
laborative care, measurement-based care, safety, and more.
HOSPITAL PSYCHIATRY
TEXTBOOK OF
Providers and policymakers agree that integrating behavioral treatments into
regular courses of patient care helps address postdischarge needs, including safe
housing, reliable transportation, and nutrition. Behavioral wellness is currently
benefiting from increased public attention, but disparities in access continue.
There is a significant need for dedicated psychiatric hospitals and dedicated units
in general hospitals to meet America’s mental health needs.
Progress is happening, but many familiar challenges remain. Inadequate health-
care coverage and reimbursement for services has left both patients and medical
providers desperate for reform. Staffing shortages are worsening as practitioners
in the baby boomer generation retire and those roles go unfilled by new graduates.
Despite these challenges, psychiatric hospitals continue to evolve and discover
new solutions to provide transformative care for patients. This updated textbook
contains valuable knowledge and novel insights for clinicians regarding treat-
ment, staffing, and care, and features new chapters on family involvement and
safety, federal and local financing, and information on collaborative care and
Lean. Forward-looking chapters focus on the integration of treatment across set-
tings and providers and examine new strategies such as telemedicine to extend
the reach of clinicians. Together, and with expert guidance, readers of this must-
have resource will find a roadmap for clinical, administrative, and financial steps
to help providers take advantage of these unprecedented times to develop ser-
vices and advance hospital psychiatry in the United States.
About the Editors

Harsh K. Trivedi, M.D., M.B.A., is President and Chief Executive Officer of
TEXTBOOK OF
HOSPITAL
Sheppard Pratt in Baltimore, Maryland.
Steven S. Sharfstein, M.D., M.P.A., is President Emeritus of Sheppard
Pratt in Baltimore, Maryland.
PSYCHIATRY
Trivedi
Sharfstein
EDITED BY
Cover design: Rick A. Prather WWW.APPI.ORG Harsh K. Trivedi, M.D., M.B.A.
Cover image: © Laura Peters
CannonDesign Steven S. Sharfstein, M.D., M.P.A.
Textbook of
Hospital Psychiatry
S E C O N D E D I T I O N
Textbook of
Hospital Psychiatry
S E C O N D E D I T I O N
Edited by
Harsh K. Trivedi, M.D., M.B.A.
President and Chief Executive Officer, Sheppard Pratt Health System
Baltimore, Maryland
Steven S. Sharfstein, M.D., M.P.A.

President Emeritus, Sheppard Pratt Health System
Baltimore, Maryland
Note: The authors have worked to ensure that all information in this book is accurate at the
time of publication and consistent with general psychiatric and medical standards, and that in-
formation concerning drug dosages, schedules, and routes of administration is accurate at the
time of publication and consistent with standards set by the U.S. Food and Drug Administra-
tion and the general medical community. As medical research and practice continue to ad-
vance, however, therapeutic standards may change. Moreover, specific situations may require
a specific therapeutic response not included in this book. For these reasons and because human
and mechanical errors sometimes occur, we recommend that readers follow the advice of phy-
sicians directly involved in their care or the care of a member of their family.
Books published by American Psychiatric Association Publishing represent the findings, conclu-
sions, and views of the individual authors and do not necessarily represent the policies and opin-
ions of American Psychiatric Association Publishing or the American Psychiatric Association.
If you wish to buy 50 or more copies of the same title, please go to www.appi.org/specialdiscounts
for more information.
Copyright © 2023 American Psychiatric Association Publishing
ALL RIGHTS RESERVED
Second Edition
Manufactured in the United States of America on acid-free paper
26 25 24 23 22 5 4 3 2 1
American Psychiatric Association Publishing
800 Maine Avenue SW
Suite 900
Washington, DC 20024-2812
www.appi.org
Library of Congress Cataloging-in-Publication Data
Names: Trivedi, Harsh K., editor. | Sharfstein, Steven S. (Steven Samuel), editor. |
American Psychiatric Association Publishing, publisher.
Title: Textbook of hospital psychiatry / edited by Harsh K. Trivedi, Steven S. Sharfstein.
Other titles: Hospital psychiatry
Description: Second edition. | Washington, DC : American Psychiatric Association Publishing,
[2023] | Includes bibliographical references and index.
Identifiers: LCCN 2022021264 (print) | LCCN 2022021265 (ebook) | ISBN 9781615373451
(hardcover ; alk. paper) | ISBN 9781615374403 (ebook)
Subjects: MESH: Psychiatric Department, Hospital—organization & administration |
Psychology, Medical—organization & administration | Hospitals, Psychiatric—
organization & administration | Mental Disorders—therapy
Classification: LCC RC439 (print) | LCC RC439 (ebook) | NLM WM 27.1 | DDC 362.2/1—
dc23/eng/20220622
LC record available at https://lccn.loc.gov/2022021264
LC ebook record available at https://lccn.loc.gov/2022021265
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
To meet a need that would otherwise be unmet...
Everything done for the comfort of the patient...
No patient to be confined below ground...
To carry forward and improve the ameliorated system

of treatment of the insane, irrespective of expense...
If five persons were returned to health and reason,

or even one, I would feel satisfied.
Moses Sheppard,
whose vision and generosity founded Sheppard Pratt in 1853
CONTENTS
Contributors . . . . . . . . . . . . . . . . . . . . xiii
Foreword . . . . . . . . . . . . . . . . . . . . . . . xix
Richard J. Pollack
Introduction . . . . . . . . . . . . . . . . . . . . .xxiii
1 History of Hospital Psychiatry . . . . . . . . . . .1

Jeffrey L. Geller, M.D., M.P.H.
Ashley J.B. MacLean, M.D.
PART 1
Inpatient Care
Units by Age Cohort
2 The Child Unit . . . . . . . . . . . . . . . . . . . . . .47

Debra Heck, M.D.
Kathryn Burns, R.N., M.S.N.
3 The Adolescent Unit . . . . . . . . . . . . . . . . . .67

Yasas Tanguturi, M.D., M.P.H.
Catharyn Turner II, M.D., M.Ed.
4 The Adult Crisis Stabilization Unit . . . . . . .87

Savitha Puttaiah, M.B.B.S., M.D.
Merle McCann, M.D.
5 The Geriatric Unit . . . . . . . . . . . . . . . . . . 113
Caitlin Lawrence, M.D.
Amy Halt, M.D., Ph.D.
Louis Marino, M.D.
Units by Diagnostic Cohort
6 The Developmental Disabilities

Co-occurring Unit: Neuropsychiatry
Across the Life Span . . . . . . . . . . . . . . . . 151
Scott R. Pekrul, M.D.
Robert W. Wisner-Carlson, M.D.
Thomas Flis, M.S.
7 The Eating Disorders Unit . . . . . . . . . . . . 183

Jennifer L. Goetz, M.D.
Steven F. Crawford, M.D.
Harry A. Brandt, M.D.
8 The Forensic Unit . . . . . . . . . . . . . . . . . . 211

Tobias D. Wasser, M.D.
Charles C. Dike, M.D., M.P.H., FRCPsych
Michael A. Norko, M.D., M.A.R.
9 The Psychotic Disorders Unit . . . . . . . . . 229

Edward Zuzarte, M.D.
John J. Boronow, M.D.
10 The Substance Use Disorders

Co-occurring Unit . . . . . . . . . . . . . . . . . . 257
Sunil Khushalani, M.D., DFAPA, FASAM
George Kolodner, M.D., DLFAPA, FASAM
Specialty Settings
11 The State Hospital . . . . . . . . . . . . . . . . . .291

Debra A. Pinals, M.D.
Brian M. Hepburn, M.D.
Ted Lutterman, B.A.
12 The Veterans Hospital . . . . . . . . . . . . . . .311

Anne Marie Stoline, M.D.
Marsden McGuire, M.D., M.B.A.
PART 2
The Continuum of Care
13 Community Mental Health and Hospital-

Based Outpatient Services . . . . . . . . . . .341
Deepak Prabhakar, M.D., M.P.H.
Manan Shah, M.D.
Jason Addison, M.D.
Jeff Richardson, M.S.W., M.B.A.
14 Residential Treatment for Children and

Adolescents . . . . . . . . . . . . . . . . . . . . . . .357
Virginia Susan Villani, M.D.
15 Residential Intensive Psychodynamic

Psychotherapy for Adults . . . . . . . . . . . . .375
Eric M. Plakun, M.D.
Edward R. Shapiro, M.D.
16 Psychiatric Emergency Services and
Interface With the General Hospital . . . . 399
Benedicto Borja, M.D.
Aaron Winkler, M.D.
Rachna Raisinghani, M.D.
PART 3
Hardwiring Excellence
17 Administration and Leadership . . . . . . . . 411

Gregory Gattman, FACHE
Kelly Savoca, CPA, M.B.A.
18 Financing of Care . . . . . . . . . . . . . . . . . . 433

Paul Summergrad, M.D., FRCPsych (Hon)
Bruce J. Schwartz, M.D.
Peter Spyrou, M.D.
19 Quality, Measurement-Based Care, and

Outcomes . . . . . . . . . . . . . . . . . . . . . . . . 447
Robert J. Schloesser, M.D.
20 Risk Management . . . . . . . . . . . . . . . . . . 463

Jerry Halverson, M.D.
Nathaniel Clark, M.D.
Terri Schultz, R.N., M.B.A.
Steven Hertig, B.A., CHPC
21 Preventing Conflict, Violence, and Use of
Seclusion and Restraint . . . . . . . . . . . . . .481
Kevin Ann Huckshorn, Ph.D., M.S.N., R.N., ICADC
Janice L. LeBel, Ph.D., ABPP
22 Lean and Operational Excellence . . . . . . .503

23 Architecture and Thoughtful Design . . . . .517

Harsh K. Trivedi, M.D., M.B.A
Michelle S. Hooper, M.S.H., AIA
Antonio DePaolo, Ph.D.
Thomas D. Hess, M.B.A.
Roger Daub
PART 4
Workforce and Special Issues
24 Psychiatrists, Psychiatric Nurse

Practitioners, and Psychologists . . . . . . .537
Todd Peters, M.D.
Kathleen Hilzendeger
25 Psychiatric Mental Health Nursing . . . . . .547

Laura Lawson Webb, M.S.N., R.N., PMHN-BC
26 Social Work and Rehabilitation

Therapies . . . . . . . . . . . . . . . . . . . . . . . . .557
Carrie Etheridge, LCSW-C
Vaune Kopeck, OTR/L
April Sobiech, LCSW-C
27 Working With Families . . . . . . . . . . . . . . . 577
Lisa B. Dixon, M.D., M.P.H.
Thomas Jewell, Ph.D.
Sarah Piscitelli, M.A.
28 From Within: A Consumer Perspective on

Psychiatric Hospitals . . . . . . . . . . . . . . . . 591
Howard D. Trachtman, B.S., CPS, CPRP, COAPS
Kenneth S. Duckworth, M.D.
Reverend Dr. Norma J. Heath
Ziona Rivera
PART 5
The Future of Hospital Psychiatry
29 Collaborative Care and Emerging

Models . . . . . . . . . . . . . . . . . . . . . . . . . . . 605
Ken C. Hopper, M.D., M.B.A.
Roger Kathol, M.D., CPE
30 The Future of Hospital Psychiatry . . . . . . 625

Jennifer Weiss Wilkerson, M.H.S.A., FACHE
Thomas Glenn, M.S.F.
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633
Color Gallery
Contributors
Jason Addison, M.D.
Sheppard Pratt Health System, Baltimore, Maryland
Benedicto Borja, M.D.

Department of Psychiatry and Behavioral Sciences, George Washington University
School of Medicine & Health Sciences, Washington, D.C.
John J. Boronow, M.D.

Harry A. Brandt, M.D.

University of Maryland School of Medicine; ERC Pathlight, Hunt Valley, Maryland
Kathryn Burns, R.N., M.S.N.

Nathaniel Clark, M.D.

Vanderbilt University School of Medicine, Nashville, Tennessee
Steven F. Crawford, M.D.

University of Maryland School of Medicine; ERC Pathlight, Hunt Valley, Maryland
Roger Daub
Hasta Advisors, LLC
Antonio DePaolo, Ph.D.

University of Maryland, Upper Chesapeake Health, Bel Air, Maryland
Charles C. Dike, M.D., M.P.H., FRCPsych

Yale University School of Medicine, New Haven, Connecticut; Connecticut Depart-
ment of Mental Health and Addiction Services, Hartford, Connecticut
xiii
xiv Textbook of Hospital Psychiatry, Second Edition
Lisa B. Dixon, M.D., M.P.H.

New York State Psychiatric Institute and Columbia University Vagelos College of
Physicians and Surgeons, New York, New York
Kenneth S. Duckworth, M.D.

NAMI: National Alliance on Mental Illness
Carrie Etheridge, LCSW-C

Thomas Flis, M.S.

Gregory Gattman, FACHE


University of Massachusetts Chan Medical School, Worcester, Massachusetts
Thomas Glenn, M.S.F.

Jennifer L. Goetz, M.D.

McLean Hospital/Harvard Medical School, Belmont, Massachusetts
Amy Halt, M.D., Ph.D.

Department of Psychiatry and Human Behavior, Brown University, Providence,
Rhode Island
Jerry Halverson, M.D.

Rogers Behavioral Health
Reverend Dr. Norma J. Heath

NAMI Greater Boston Peer Support and Advocacy Network; AMRON International
Debra Heck, M.D.

Brian M. Hepburn, M.D.

National Association of State Mental Health Program Directors, Alexandria, Virginia
Steven Hertig, B.A., CHPC

Rogers Behavioral Health
Thomas D. Hess, M.B.A.

Kathleen Hilzendeger
Michelle S. Hooper, M.S.H., AIA

Marshall Craft Associates, Inc., Baltimore, Maryland
Ken C. Hopper, M.D., M.B.A.

TCU and UNTHSC School of Medicine, Fort Worth, Texas
Contributors xv
Kevin Ann Huckshorn, Ph.D., R.N., M.S.N., ICADC

Recovery International, Inc.
Thomas Jewell, Ph.D.

New York State Psychiatric Institute and Columbia University, Department of Psychi-
atry, New York, New York
Roger Kathol, M.D, CPE

University of Minnesota, Minneapolis, Minnesota

Kolmac Outpatient Recovery Centers; Department of Psychiatry, University of Mary-
land School of Medicine, Baltimore, Maryland
George Kolodner, M.D., DLFAPA, FASAM

Georgetown University School of Medicine, Washington, D.C.
Vaune Kopeck, OTR/L

Caitlin Lawrence, M.D.

Department of Psychiatry and Human Behavior, Brown University, Providence,
Rhode Island
Janice L. LeBel, Ph.D., ABPP

Department of Mental Health, Commonwealth of Massachusetts
Ted Lutterman, B.A.

NRI, Falls Church, Virginia

University of Massachusetts Chan Medical School, Worcester, Massachusetts
Louis Marino, M.D.

Sheppard Pratt Health System, Baltimore, Maryland; Department of Psychiatry and
Human Behavior, Brown University, Providence, Rhode Island
Merle McCann, M.D.

Marsden McGuire, M.D., M.B.A.

Department of Veterans Affairs, Washington, D.C.
Michael A. Norko, M.D., M.A.R.

Yale School of Medicine, New Haven, Connecticut; Connecticut Department of Men-
tal Health and Addiction Services, Hartford, Connecticut
Scott R. Pekrul, M.D.

Todd Peters, M.D.

Debra A. Pinals, M.D.

University of Michigan Medical School, Ann Arbor, Michigan
xvi Textbook of Hospital Psychiatry, Second Edition
Sarah Piscitelli, M.A.

New York State Psychiatric Institute, New York, New York
Eric M. Plakun, M.D.

Austen Riggs Center, Stockbridge, Massachusetts

Savitha Puttaiah, MB.B.S., M.D.

Baptist Behavioral Health, Jacksonville, Florida
Rachna Raisinghani, M.D.

Jeff Richardson, M.S.W., M.B.A.

Ziona Rivera
NAMI Greater Boston Peer Support and Advocacy Network; AMRON International
Kelly Savoca, CPA, M.B.A.

Robert J. Schloesser, M.D.

Terri Schultz, R.N., M.B.A.

Department of Compliance and Regulation, Rogers Memorial Hospital, Inc.
Bruce J. Schwartz, M.D.

Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center and
Albert Einstein College of Medicine, Bronx, New York
Manan Shah, M.D.

Edward R. Shapiro, M.D.

Austen Riggs Center, Stockbridge, Massachusetts; Clinical Professor of Psychiatry,
Yale Medical School, New Haven, Connecticut

April Sobiech, LCSW-C

Peter Spyrou, M.D.

Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center and
Albert Einstein College of Medicine, Bronx, New York
Anne Marie Stoline, M.D.

Perry Point VA Medical Center, Perry Point, Maryland
Contributors xvii
Paul Summergrad, M.D., FRCPsych (Hon)

Department of Psychiatry, Tufts University School of Medicine; Tufts Medical Center
and Tufts Children’s Hospital, Boston, Massachusetts; World Psychiatric Association
Yasas Tanguturi, M.D., M.P.H.

Vanderbilt Psychiatric Hospital; Vanderbilt University Medical Center, Nashville,
Tennessee
Howard D. Trachtman, B.S., CPS, CPRP, COAPS

NAMI Greater Boston Peer Support and Advocacy Network

Catharyn Turner II, M.D., M.Ed.

Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
Virginia Susan Villani, M.D.

Tobias D. Wasser, M.D.

Yale School of Medicine, New Haven, Connecticut; Whiting Forensic Hospital, Mid-
dletown, Connecticut
Laura Lawson Webb, M.S.N., R.N., PMHN-BC

Jennifer Weiss Wilkerson, M.H.S.A., FACHE

Aaron Winkler, M.D.

University of Maryland/Sheppard Pratt, Baltimore, Maryland
Robert W. Wisner-Carlson, M.D.

Edward Zuzarte, M.D.

Foreword
With each passing day, the words of Dr. Brock Chisholm, the first director-general
of the World Health Organization and a psychiatrist, become increasingly clear:
“Without mental health there can be no true physical health.” The American Hospital
Association sees this link throughout our membership, which includes freestanding
psychiatric hospitals, psychiatric units within general acute care facilities, and millions
of individual clinicians. Even with improved access to community-based care, severely
ill patients continue to need the intense and highly tailored medical treatments—for
both mental and physical comorbidities—that are provided only in hospitals. As we
continue to confront COVID-19, the world’s greatest public health crisis in the past
century, it is astounding how much has changed since the last published edition of this
textbook . . . and how much remains the same.
Over the last decade, the field of hospital psychiatry has faced new clinical and pol-
icy challenges and opportunities. Spending by insurers for behavioral health treat-
ments has increased significantly, and out-of-pocket spending for behavioral health
treatments continues to rise. Accompanying this increase in spending is the nationwide
explosion of the opioid crisis, which reminds us of the insidious entanglements of pain
and addiction. Increasingly, patients seeking psychiatric care in hospitals suffer from a
combination of behavioral and physical ailments, each exacerbating the others, result-
ing in highly sensitive and complex treatment regimens. As providers treat patients with
complex conditions, they also must balance the growing regulatory demands, quality
reporting programs, and progressively stricter survey and certification activities that
have heaped numerous administrative requirements on hospitals. The ensuing envi-
ronment of care is a constant juggling act of these pressures with efforts to advance ev-
idence-based care protocols and quality improvement initiatives.
Even in the face of these obstacles, the field has expanded and treatment has
evolved. Providers and policy-makers are increasingly aware of the importance of treat-
xix
xx Textbook of Hospital Psychiatry, Second Edition
ing the whole person. Research demonstrates that integrating physical and behav-
ioral health care improves outcomes and can reduce the total cost of care. Clinicians
across specialties are adding behavioral health treatment into their regular courses of
care, while psychiatric facilities and units address not only patients’ physical ailments
but also their postdischarge social needs, including housing, transportation, and nu-
trition. Many psychiatric facilities also are improving their health information tech-
nology capabilities to enhance care through the use of electronic medical records and
telepsychiatry.
As the field has made progress in a number of areas, many age-old challenges remain.
Inadequate reimbursement and insurance coverage for mental illnesses leave both
patients and providers desperate for reform. Despite the passage of the Mental
Health Parity and Addiction Equity Act in 2008, patients seeking mental health care
are twice as likely to be denied coverage for services based on medical necessity as pa-
tients seeking physical health care, and behavioral health providers are still reimbursed
less than those in other specialties. In addition, the long-standing workforce shortages
are worsening, as practitioners in the baby boomer generation reach retirement age and
their roles go unfilled by new graduates. The shortages are particularly severe in child,
adolescent, and geriatric psychiatry.
These obstacles feed on and into pervasive undercurrents that have been present
since the inception of hospital psychiatry. Disparities in access still leave people of color
struggling to receive care at all, let alone culturally competent treatment. Individuals
in the LGBTQ+ community are more likely to attempt or commit suicide, particularly
during adolescence. The aging population is more likely than previous generations to
live alone and without behavioral and social supports. And underscoring it all is the
stigma associated with mental illness and substance use disorders. While it is encour-
aging that behavioral wellness has received some increased public attention, including
from well-known personalities, unfortunately severe mental illnesses like schizophre-
nia and other psychotic disorders (the second most common diagnostic group treated
in psychiatric hospitals) are associated with even higher levels of stigma than other
behavioral health conditions.
Despite this intimidating environment, psychiatric hospitals are adapting and find-
ing new ways of caring for severely ill patients. This textbook orients the practice of
hospital psychiatry toward the future while seeking innovative solutions to these long-
standing challenges. The forward-looking chapters focus on integrating physical and
behavioral health care across specialty units, types of hospitals, and treatment settings.
Authors at the vanguard of their field offer insights into modern delivery models that
employ strategies such as telemedicine to extend the reach of the clinical workforce.
Other chapters expound on the utility of collaborative care efforts, which incorporate
professionals from various specialties, to address the full continuum of a patient’s
needs. Hospital and health system leaders extend guidance on the infrastructure ca-
pabilities necessary to balance the many, and often competing, clinical and adminis-
trative demands.
It is fitting that this new edition arrives following the tumultuous year of 2020. The
COVID-19 pandemic, social and civil unrest, and the economic recession laid bare the
critical and urgent need for behavioral health care. On the one hand, the events of that
year have seriously affected the mental health of individuals across the nation, resulting
in increases in depression, anxiety, drug overdoses, and self-harm. On the other, the
Foreword xxi
surge in awareness of the importance of behavioral health care has hastened policy
actions to enhance funding and ease regulatory burdens on psychiatric providers. This
textbook will help the field take advantage of this historic and unprecedented oppor-
tunity to advance hospital psychiatry.
The American Hospital Association is proud to represent practitioners who face
such a complex and challenging environment with integrity and compassion. As we
strive to ensure a regulatory environment that reduces burden and supports innova-
tion, clinicians work tirelessly to provide evidence-based, high-quality, and safe care to
patients with acute conditions that are among the most difficult to treat. Together, and
with the guidance of the experts featured in this textbook, we hope to continue to advance
the practice of hospital psychiatry as we work to advance health in America.
Richard J. Pollack
President and Chief Executive Officer
American Hospital Association
Introduction
Sheppard Pratt is the largest private, nonprofit provider of mental

health, substance use, developmental disability, special education, and social services
in the nation. Our path is one that has been marked with tremendous growth, par-
ticularly during the most difficult time periods in our field. As only the fifth and sixth
chief executive officers for Sheppard Pratt Health System since its founding in 1853,
we have chosen to chart a course that is unique among freestanding psychiatric hos-
pitals, and as time has progressed, we remain unparalleled in our ability not just to
survive but to adapt and thrive to meet the most pressing need of each decade.
Our 5,000 employees provide psychiatric care across 160 unique programs at more
than 380 sites of service. The health system provides the most comprehensive behavioral
health continuum, serving patients from more than 40 states and 20 foreign countries
annually. As a nationally ranked top hospital in psychiatry by U.S. News & World Re-
port for 30 consecutive years, each year we base our success on how many more people
we can help, how many new programs we can create, how we can accept all who need
care regardless of their ability to pay, and how we can lead in transforming our field to
ensure that every community has access to high-quality psychiatric services.
We hope that the knowledge contained within this textbook will provide valuable
knowledge to spur innovation and growth within your own organization as well as
provide hope for what is possible in our field. While we acknowledge that many de-
velopments are happening at places across the country, we fundamentally believe in
three guiding principles that are even more true today than in previous decades: 1) the
importance of having a true system of care that spans the continuum of services that
patients need for each step in their care journey, 2) the importance of being able to of-
fer services at scale and to ensure access to all comers, regardless of severity of illness
or payer-type, and 3) the increasing importance of having a physician executive at the
xxiii
xxiv Textbook of Hospital Psychiatry, Second Edition
helm of leadership to manage clinical complexity across programs and services, to

drive clinical outcomes for each patient, and to generate population-level impact.
Evolution of the Textbook of Hospital Psychiatry

In the past quarter century, hospital psychiatry has been transformed. More psychi-
atric patients have been treated as inpatients for short stays and then moved into a
continuum of care with varying degrees of success and intensity. The very definition of
“hospital” has changed from inpatient treatment to crisis stabilization, then discharge
to step-down day treatment, intensive outpatient treatment, supportive housing, and
other community mental health services. This is true for specialty psychiatric hospitals,
whether nonprofit or for profit, and for specialty units in general hospitals, which of-
fer the most common setting for a short inpatient stay. Public hospitals across the na-
tion have closed or downsized and are primarily utilized for court-ordered evaluation
and treatment.
The original Textbook of Hospital Psychiatry published in 2009 (Sharfstein et al. 2009)
was the first textbook to describe the new twenty-first-century managed-care realities
for acute inpatient care and the promise of the effectiveness of psychiatric hospital-
ization as a critical part of recovery from serious mental illness. The redefinition of the
hospital from longer-term, 24-hour inpatient care has continued over the nearly 15 years
since publication of the first edition to a “hospital without walls,” the subspecializa-
tion of care by diagnosis and age, and the increased sophistication of treatment and
care. However, as we know more of what can be done, we are more aware of the short-
falls in the opportunities for treatment and care for patients with psychiatric disorders
in America today.
This second edition is intended to energize the field to advance care and to advocate
for the funding needed to implement state-of-the-art care in every community. An im-
portant issue across our country and internationally is how many beds are necessary
to meet the needs of the mentally ill. The answer, as you will learn, depends on the
definition of a psychiatric bed, the role of inpatient care within a system or continuum
of care, and both the availability and the accessibility of a range of hospital-based
stepdown services, outpatient community options, supported housing, psychosocial
rehabilitation, and supported employment services.
Organization of Textbook of Hospital Psychiatry

This book is organized into five major parts, as described below.
Inpatient Care
This portion of the textbook reflects the types of inpatient units commonly seen across
the nation. It is organized into sections in terms of both units by age cohort and units
by diagnostic cohort. It is our belief that for specific psychiatric conditions, such as
psychosis or eating disorders, the availability of specialized units with dedicated,
trained staff allows for better care. Chapters follow that discuss the role of the state
hospital and veterans hospital in psychiatric inpatient care. Beyond the specific types
Introduction xxv
of inpatient units, two major concepts exist: the existence or availability of psychiatric
beds and the accessibility of those beds to all who need inpatient care.
Regarding availability of psychiatric beds, we have come a long way from the peak
of public asylum psychiatry in 1955, when there were 559,000 individuals in psychi-
atric beds and length of stay was calculated in months or even years and lifetimes.
State mental hospitals have been depopulated so that there are fewer than 40,000 beds
in state hospitals, and these are largely forensic. In addition, there are 31,000 beds on
psychiatric units in general hospitals, 25,000 beds in private psychiatric hospitals,
3,000 beds in Veterans Affairs hospitals, and 3,500 beds in other specialty mental health
centers (Pinals and Fuller 2017). In the United States, we have 21 beds per 100,000 pop-
ulation according to the Organisation for Economic Co-operation and Development
(OECD), as compared with an OECD average of 70 beds per 100,000. Only Chile, Italy,
and Mexico have fewer.
In addition to availability of beds, it is important to note that access to psychiatric
beds also remains a critical issue. With passage of legislation ensuring mental health
parity, the substantial gains that were expected in access have not materialized because
of lack of enforcement at the state level. Beyond the structure of the health benefits,
insurers have attempted to change their internal definitions of what is covered and
what is medically necessary. The landmark class action lawsuit Wit v. United Behav-
ioral Health decision found that the insurer internally developed coverage determina-
tion guidelines and level of care guidelines more stringent than accepted standards
to wrongfully deny care. A positive development in recent years has been the open-
ness of younger generations in the United States and internationally about their men-
tal health needs. They are actively demanding that their health insurance provide
meaningful access to covered services, without the concerns for stigma that have pre-
vented more of these issues from coming to light.
And while we cringe at the unscrupulous behavior of for-profit insurance compa-
nies, our largest federal payer of care for low-income individuals stands out for its
own discriminatory practice. Indeed, the only section of “Medicaid law that prohibits
federal payment for medically necessary care simply because of the type of illness be-
ing treated” (Treatment Advocacy Center 2016) is Medicaid’s anachronistic institu-
tion for mental diseases, or IMD, exclusion. It restricts federal financial participation
for individuals in the exclusion group and prevents access to inpatient psychiatric
care for an entire population of people, particularly those with serious mental illness
and those with comorbid substance use issues.
There is a significant role for psychiatric hospitals and psychiatric units in general
hospitals in meeting mental health needs nationally. The impact of the COVID-19 pan-
demic on mental health and predicted increases in suicides and overdoses will only ex-
acerbate availability and access issues for inpatient psychiatric beds.
We fundamentally believe that through the work of behavioral health integration,
greater understanding of the impact of untreated and undertreated mental health on
health outcomes, and the national need to better manage spiraling health care costs,
psychiatric care will be thrust forward for the integral role it plays in overall health and
as a driver of reducing the total cost of care. As these shifts occur, we are confident that
a new national resource will emerge, the specialty psychiatric hospital—such as
Sheppard Pratt. Throughout the nation, a handful of dedicated comprehensive spe-
cialty psychiatric hospitals will emerge—expert at managing all diagnoses, for all com-
xxvi Textbook of Hospital Psychiatry, Second Edition
ers, with a comprehensive continuum of services, and able to manage the most complex
cases in the nation. This comprehensive national resource will be a beacon of hope
and a guiding force for best practice implementation, similar to the role of a specialty
cancer hospital, a specialty orthopedic hospital, or a specialty cardiac hospital.
The Continuum of Care

The psychiatric hospital today, much like the rest of medicine, goes beyond the hos-
pital walls and offers more than just an inpatient bed. This textbook is about the rich-
ness and diversity of levels of care, sites of care, and types of programs. While many
communities experience a gap in the continuum of care, we are proud to share the
broad system of care that Sheppard Pratt has created and refined over the course of
decades. First starting most proximal to the inpatient unit, this portion of the textbook
discusses hospital-based outpatient services. Residential treatment programs, day
hospitals, intensive outpatient programs, specialty outpatient programs—all are part
of the changing landscape of psychiatric treatment.
We end this part with a look at psychiatric emergency services, crisis stabilization,
and the interface with the general hospital. The adolescent at risk for suicide and their
family require a different approach than the aggressive geriatric patient admitted from
a nursing home with dementia. Patients with co-occurring substance use and mental dis-
orders, patients with eating disorders, and patients with co-occurring neurodevelop-
mental and mental disorders each require different approaches. The path forward is
one in which we do not treat “mental illness” as a vanilla term that encompasses ev-
ery DSM diagnosis and places people in general programs that try to treat every men-
tal health issue within the same program. Rather, the path forward is more specific
treatment based on the clinical needs of the patient, marked by the utilization of ill-
ness-specific treatment tracks and specialty programs for chronic disease management.
Hardwiring Excellence
As the field of psychiatry has progressed, so have the knowledge and expertise re-
quired to operate a high-quality, efficient, highly reliable, and fiscally sound hospital
or health system. This portion of the textbook covers vital topics related to leadership,
strategic planning, financial matters, and operational excellence. It delves into qual-
ity, safety, and risk management in hospital settings. It focuses on preventing conflict,
violence, and use of seclusion and restraint. And, should you find yourself in the en-
viable role of getting to design a new space or remodel an existing space, it discusses
the importance of design and architecture in creating a therapeutic space, engineering
safety, and achieving optimal design for peak clinical and operational performance.
This newest version of the Textbook of Hospital Psychiatry was written to coincide
with the unveiling of Sheppard Pratt’s newest, state-of-the-art $150 million psychiat-
ric hospital in the Baltimore-Washington corridor in July 2021. This hospital and its
new 50-acre campus are a testament to the vision, strategic execution, and strong fi-
nancial standing of Sheppard Pratt. This portion of the textbook defines the critical
elements of why our path has been unique and unparalleled thus far in the field. The
ability to build high-quality programs to scale and create the continuum of services
to match the patient’s journey is fundamental to good clinical care.
Introduction xxvii
Workforce and Special Issues

Buildings are just buildings, but it is the people who infuse the care that breathes life
and purpose to nurture hope and healing. This portion of the textbook covers the ar-
ray of clinicians on a multidisciplinary care team and professional issues for each pro-
fession. It then expands to discuss working with families and presents a consumer
perspective on psychiatric hospitals.
The Future of Hospital Psychiatry

The book ends with two impactful chapters. The substantial progress that will occur
between now and the third edition of this textbook will be more seamless integration
of behavioral health services across primary care and throughout medicine. The
chapter on collaborative care and emerging models discusses a number of those ef-
forts and ones that will indeed grow in the coming decade. The final chapter charts the
path forward for the field of hospital psychiatry. It presents key disruptive forces as
well as likely advances that will advance care in the years to come.
Final Thoughts
It is our hope that the knowledge provided in this textbook will help you to achieve
meaningful advances in care in your programs and services. The images throughout the
text reflect pictures of actual care settings. The descriptions of services are built and
at scale. And they are provided with the aim of inspiring you and showing what is
truly possible. We must each strive to implement meaningful change, to build new pro-
grams that create new access, and to advocate for appropriate funding of psychiatric
care so that every individual can access lifesaving and life-changing care when they
need it.
Acknowledgment
The editors would like to express their appreciation to Janet Bryan and Tamara
Chumley for their help in the preparation of this manuscript. Their administrative
skills in dealing with multiple authors, as well as the editors, during an unprece-
dented pandemic kept this work on track and (mostly) on time. Thank you.

References
Pinals DA, Fuller DA: Beyond Beds: The Vital Role of a Full Continuum of Psychiatric Care. Al-
exandria, VA, National Association of State Mental Health Program Directors, 2017. Avail-
able at: www.nasmhpd.org/sites/default/files/TAC.Paper_.1Beyond_Beds.pdf. Ac-
cessed December 12, 2020.
xxviii Textbook of Hospital Psychiatry, Second Edition
Sharfstein SS, Dickerson FB, Oldham JM (eds): Textbook of Hospital Psychiatry. Washington,
DC, American Psychiatric Publishing, 2009
Treatment Advocacy Center: The Medicaid IMD Exclusion and Mental Illness Discrimination.
Alexandria, VA, Treatment Advocacy Center, 2016. Available at: www.treatmentadvocacy-
center.org/storage/documents/backgrounders/imd-exclusion-and-discrimination.pdf.
Accessed January 19, 2021.
CHAPTER 1
History of
Hospital Psychiatry
The history of American psychiatry is fundamentally

the history of inpatient psychiatry. Every generation in our nation’s history has faced
mental health as a significant societal challenge. While the methods of treatment have
varied over time, what has been constant is the presence of stigma and the lack of full
funding of adequate mental health services. Many original psychiatric hospitals have
closed, and there has been a dramatic reduction in the availability of inpatient psychi-
atric beds in most communities nationally. Inadequate funding has led to an arbitrary
pitting of various segments of care against one another. Examples include inpatient
care versus community psychiatry and mental health versus substance use service fund-
ing. The separation of federal and local streams of funding for mental health, substance
use disorders, developmental disorders, and social services has led to structural
inabilities to provide comprehensive treatment planning and improved outcomes.
Insurance, regulatory, and legislative barriers lead to suboptimal access to hospital-
based psychiatry. Antiquated constructs of institutions for mental diseases (IMD) exclu-
sion and discriminatory payment practices despite mental health parity remain barriers
to effectuating the best outcome for the individual.
The architects of the American Psychiatric Association (APA) were founders of an
association of medical superintendents, some from state hospitals, others from private
1
2 Textbook of Hospital Psychiatry, Second Edition
FIGURE 1–1. Samuel Bayard Woodward.

Source. John Curwen: The Original Thirteen Members of the Association of Medical Superintendents of American
Institutions for the Insane. Courtesy of American Psychiatric Association Archives, Washington, D.C.
psychiatric hospitals. Nine of the original 13 members of the Association of Medical

Superintendents of American Institutions for the Insane (AMSAII) had connections
with private psychiatric hospitals. In 1844, they met in Philadelphia and established
the first medical specialty organization in the United States. Thomas Story Kirkbride
had trained at Friends Asylum and was superintendent of the Pennsylvania Hospital
for the Insane. Samuel Bayard Woodward (Figure 1–1), Amariah Brigham, and John
Butler had all been associated with the Hartford Retreat; Isaac Ray was connected
with Butler Hospital; and Pliny Earle (Figure 1–2) had associations with both Friends
and Bloomingdale Asylums. Two members, Nehemiah Cutter (Pepperell Private
Asylum) and Samuel White (Hudson Lunatic Asylum), were founders of and ran
proprietary psychiatric facilities, and Luther Vose Bell (Figure 1–3) headed McLean
Asylum. These founders of American psychiatry, and the hospitals with which each
was associated, set the course for hospital-based care and treatment.
The Early Years (The Beginning Through 1920)
Origins of Public Facilities

Public care of persons with insanity began concurrently at multiple levels of govern-
ment. Prior to the nineteenth century, the care of insane persons was predominantly
a local endeavor, took place largely in almshouses, and was generally custodial in na-
History of Hospital Psychiatry 3
FIGURE 1–2. Pliny Earle.

ture (Hurd 1916–1917). When states took responsibility for insane paupers in this era,
the state would auction these “confessedly undesirable persons” to the lowest bidder,
because the state had to pay the private family to provide for the basic needs. If no
family could be found, jails or strong pens under a relative’s supervision were used
(Deutsch 1949; Hurd 1916–1917).
In some states, care for the insane poor became organized at the county level. States
created state boards of charity to inspect the county establishments that housed in-
sane persons. This system was criticized because local variation was extreme and
medical and nursing interventions were generally poor (Hurd 1916–1917).
At the outset, “state care” meant care received at a state institution that was estab-
lished, built, and managed by the state but whose operation was funded by taxpayers
and individuals. These were strictly speaking state-aided facilities. If the patient or
family had resources, they paid for care; paupers were the responsibility of the
county. Thus, the earliest public facilities—in Williamsburg, Virginia, and Columbia,
South Carolina—were established pursuant to this model (Hurd 1916–1917).
State care in which the state was responsible for all insane persons and executed its
responsibility through state-managed and funded hospitals began with Worcester
State Hospital in 1833 (Hurd 1916–1917) (Figure 1–4). The development of state care
progressed at quite different rates. New Hampshire, for example, did not have an act
legalizing state care until 1913 (Hurd 1916–1917).
It was three decades after states began to take responsibility for their insane popu-
lations that states started to specifically consider the incurably insane. In 1865, New
FIGURE 1–3. Luther Vose Bell.

York established the first asylum for persons with chronic insanity, the Willard Asy-
lum for the Chronic Insane (Figure 1–5) (Deutsch 1949; Hurd 1916–1917). Not everyone
was in favor of such institutions. Amariah Brigham (Figure 1–6), first superintendent
of Utica State Hospital, in a letter to Dorothea Dix in 1866, indicated that he opposed
“the establishment of hospitals solely for the incurable insane. They would, in my opin-
ion, soon become objects of but little interest to any one, and where misrule, neglect,
and all kinds of abuse would exist and exist without detection” (quoted in Deutsch 1949,
p. 239).
At this same time, the members of the AMSAII articulated, at their annual meeting,
what they believed the states’ responsibilities were (Hurd 1916–1917):
1. The state should make ample and suitable provisions for all its insane.
2. No insane person should be treated in any county poorhouse or almshouse.
3. Proper classification is an indispensable element and can only be achieved in fa-
cilities specifically constructed for treatment.
4. Curable and incurable persons should not be in separate establishments.
5. States should have asylums placed so that individuals can get treatment near
where they reside.
6. Hospitals should have enough wards to treat different classes of insane persons
on different wards.
7. Hospitals could have up to 600 patients and properly care for the insane.
FIGURE 1–4. Worcester State Hospital.

Source. Courtesy of National Library of Medicine, Bethesda, Maryland.
In 1868, the AMSAII drafted suggested legislation concerning the admittance of

patients (Hurd 1916–1917):
1. Insane persons may be placed in a hospital for the insane by their relatives, friends,
or legal guardian, but never without the certificate of one or more reputable phy-
sicians, after a personal examination, made within 1 week.
2. Insane persons may be placed in a hospital by order of a magistrate who, after proper
inquisition, finds that such persons are at large and dangerous to themselves or
others or require hospital care and treatment; the fact of their insanity shall be cer-
tified as specified in the preceding section.
3. Insane persons may be placed in a hospital, by order of any high judicial officer,
if, on statement in writing of any respectable individual that a certain person is in-
sane, and that the welfare of himself or others requires his restraint, a duly ap-
pointed commission finds the person is a suitable case for confinement.
Origins of Private Psychiatric Hospitals

Three facilities began as parts of general medical hospitals. The Institute of the Penn-
sylvania Hospital started in the general hospital proposed by Benjamin Franklin,
with insane persons scattered throughout the hospital, mostly in cellars. A separate
wing of the general hospital was then completed, followed finally by a separate struc-
ture built in west Philadelphia, some distance from the general hospital, and funded
by a colonial grant and subscriptions (Deutsch 1949; Kirkbride 1845).
FIGURE 1–5. Willard State Hospital (formerly Willard Asylum for the Chronic Insane).
Source. Courtesy of American Psychiatric Association Archives, Washington, D.C.
The Bloomingdale Hospital in New York (Figure 1–7) began as a wing of a general
hospital, funded by subscriptions from “philanthropic public spirited” citizens. The
locus of care of the insane moved to a separate structure with a grant from the state
(Deutsch 1949; Earle 1845).
McLean Hospital in Massachusetts started as part of a general hospital, but services
for insane persons were provided in a separate facility from the outset. Initial funding
was from bequests, subscriptions, and donations; 3 years after it opened, John McLean
of Boston willed $100,000 to the asylum, and the asylum was renamed in his honor
(Deutsch 1949; Massachusetts 1845).
Three private psychiatric hospitals began as freestanding institutions funded through
different methods. Butler Hospital in Rhode Island (Figure 1–8) resulted from the legacy
of a philanthropist, Nicholas Brown, and from a subscription campaign, with the major
contributions coming from Cyrus Butler at the urging of Dorothea Dix (Deutsch 1949;
Ray 1848). The Brattleboro Retreat, which began as the Vermont Asylum for the In-
sane, was funded through a bequest by the wife of a physician, with additional funds
provided by the state (Deutsch 1949). The Hartford Retreat in Connecticut (subsequently
named the Institute of Living) (Figure 1–9) resulted from a study by the Connecticut
Medical Society that recommended the construction of a freestanding mental institu-
FIGURE 1–6. Amariah Brigham.

tion. The retreat was funded by a state grant, funds from the state medical society, pri-
vate subscriptions, and a lottery (Connecticut 1845; Deutsch 1949). Two private
hospitals were begun by religious organizations. The Friends Asylum in Pennsylvania
was initiated by the Society of Friends. Modeled after the English Quakers’ York Re-
treat, the Friends Asylum was funded by a subscription campaign and in-kind dona-
tions. The hospital was established to serve only members of the Society of Friends, but
from 1834 to 1845 others were admitted. In 1845, admissions were limited to those con-
nected with the Society of Friends and any others who were former patients (Deutsch
1949; Pennsylvania 1845).
Whereas all of these hospitals were formed under a for-profit model, the Mount
Hope Institution in Maryland, which began as Mount Saint Vincent, was based on re-
ligious benevolence. Although a Catholic-affiliated institution, it accepted patients of
all denominations.
The origins of many of the smaller facilities are much more obscure; many appear to
have been set up as a form of private practice. Some that began in the early twentieth
century, such as Chestnut Lodge and the Austen Riggs Center, were established as ven-
ues to practice certain types of psychiatry (Geller 2006). An interesting thesis for the
founding of many nineteenth-century facilities is that physicians who had worked in the
public sector needed income-producing ventures later in their careers because there was
no public pension or retirement system (Gerald Grob, personal communication, No-
vember 2000). A few additional hospitals were created in a fashion similar to the earliest
FIGURE 1–7. Bloomingdale Asylum (Bloomingdale Hospital), New York.

Source. Colored wood engraving. Courtesy of Wellcome Collection. Public Domain Mark.
asylums. Moses Sheppard planned for the establishment of a mental institution in Mary-
land and built a hospital that opened as the Sheppard Asylum (Figure 1–10). With a sub-
sequent bequest from Enoch Pratt, the facility was renamed Sheppard and Enoch Pratt
Hospital (Forbush 1971). Edward Jarvis, himself an operator of a private facility in Mas-
sachusetts, stated in 1860 that the role of the private facility was
not to compete with the public institutions in matters of cheapness; but to provide lib-
erally for all the proper wants of their inmates, and charge all for material, time, atten-
tion and responsibility, and receive a corresponding reward.
Not to receive and treat the violent, the maniacal, the suicidal; but the mild, quiet, and
manageable by personal influence.
And principally to provide and offer to such patients as can properly enjoy and profit
by them, an opportunity of using more of their faculties that are sane, a freer range of
occupation and action, more of domestic and social life, more intercourse with the
FIGURE 1–8. Butler Hospital, Providence, Rhode Island.

Source. American Journal of Insanity, Vol. 5, frontis. Courtesy of National Library of Medicine, Bethesda,
Maryland.
world, and a condition resembling more nearly that of their own homes than can be of-
fered and enjoyed in the public hospitals. (Jarvis 1860, p. 31)
Private-Public Interface
Of the larger private facilities, all but one preceded the state’s first public hospital,
sometimes by more than 50 years. The private hospitals met a state’s need for care of
indigent insane persons by admitting “public” patients with varying methods of pay-
ment. This arrangement generally continued until the state determined it could pro-
vide for those insane who required public support more cost-effectively in state
hospitals. Bloomingdale Asylum was aided by legislative appropriations for its first
30 years; this ended in 1849, and the facility then devoted itself to private patients
only (New York 1872). William Rockwell, superintendent of the Vermont Asylum for
the Insane (Brattleboro Retreat), proclaimed in 1867 that his hospital could accommo-
date all insane persons of Vermont who required hospital treatment (Vermont Asy-
lum for the Insane 1868). The Hartford Retreat ended its relationship with the state of
Connecticut after 30 years of “receiving such insane patients as were a public charge”
(Connecticut 1871). Butler Hospital received an annual appropriation from the state
that could be apportioned to specific patients at a fixed annual cap per patient (Butler
Hospital for the Insane 1878). This continued even after Butler Hospital sent a large
number of the indigent insane patients to the state facility at its opening. Pennsylva-
nia Hospital (Figure 1–11) provided care to a limited number from the state, doing so
“without charge of any kind” (Kirkbride 1845).
FIGURE 1–9. Hartford Retreat, Hartford, Connecticut.

Source. American Journal of Insanity, v. 5, frontis. Courtesy of National Library of Medicine, Bethesda,
Maryland.
A social policy evolved in virtually every state that care of its insane citizens would
predominantly be a public function. Despite the operation of many private facilities,
these accounted for a small percentage of institutionalized persons by the early twen-
tieth century. On January 1, 1920, there were 232,680 persons in institutions for mental
disorders in the United States: 200,109 in state hospitals, 21,584 in county or city facil-
ities, 1,040 in institutions for temporary care, 709 in Public Health Service hospitals,
and 9,238 in private hospitals (Pollock and Forbush 1921). Thus, private facilities ac-
counted for only 4% of persons in psychiatric facilities.
Comparison of Private and Public Facilities

It should come as no surprise that public and private facilities had some common fea-
tures, because the establishment of many public asylums was directly influenced by
the early private asylums. The Friends Asylum and Hartford Retreat influenced the
erection and organization of Utica State Hospital (Figure 1–12); the Hartford Retreat
affected the establishment of asylums in Worcester and Boston, Massachusetts; and
the Brattleboro Retreat influenced the construction of the state asylum in New Hamp-
shire (Hurd 1913).
At the turn of the twentieth century, the president of the New York State Commis-
sion in Lunacy argued that both public and private facilities should be able to admit pa-
tients for 48–72 hours on an emergency paper signed by a family physician. “Regular
lunacy certification” would follow, and thus the use of jails and prisons for the reception
FIGURE 1–10. Sheppard Asylum.

Source. Courtesy of Sheppard and Enoch Pratt Hospital.
of persons “ill of brain disease” could be avoided (Peterson 1902). During the first two
decades of the twentieth century, both public and private hospitals had open, un-
locked wards, and both were striving to treat patients without the use of seclusion or
restraint (Hurd 1916–1917; Page 1904).
Private facilities, like public ones, had issues with overcrowding (“Vermont”
1890), psychiatrists’ violent deaths at the facility (“Death of Dr. George Cook” 1876),
unwarranted admissions (“From the Report of the McLean Asylum” 1864), allega-
tions of abuse (Stewart 1874), and stigma (Parsons 1881). Accounts decrying inappro-
priate admissions and ill treatment can be found from former patients of both public
and private facilities (Geller and Harris 1994).
By the 1880s, most psychiatrists agreed that “insane patients can best be managed
away from their own homes” (Parsons 1881, p. 586). Some psychiatrists postulated
that “well-equipped and well-managed asylums for the insane are among the most
important of the outgrowths of modern civilization and benevolence” (Parsons 1881,
p. 567).
The private facilities were established for wealthier persons able to pay for more
comfort, “suitable medical treatment,” and “pursuits and diversions which are most
congenial and desirable” (“Private Asylums” 1879, p. 243). Patients were such that
when “you encounter persons variously occupied...you find yourself not infrequently
quite at a loss to determine whether the persons met with are really the insane, or
whether they may be visitors or officials in the establishment” (Wood 1853, p. 212).
Private facilities allowed “more judicious social intercourse with the sane,” greater
personal freedom, more individuation of treatment, closer approximation to family
life, greater ratios of physicians and attendants, and less use of “locked and bolted
doors, and of barred windows” (Parsons 1881, p. 575). Public hospitals were entities
of state, county, or municipal governments, and by mid-nineteenth century states had
moved to centralize control and to decrease asylum superintendents’ autonomy (Grob
1983). States’ oversight over private facilities was extremely variable. By 1910, private
FIGURE 1–11. Kirkbride’s Hospital (Institute of the Pennsylvania Hospital), Philadelphia,

Pennsylvania.
Source. Courtesy of American Psychiatric Association Archives, Washington, D.C.
facilities came under the oversight of some form of a state board in 16 states. Three other
states had alternative methods of oversight. In 11 states, private facilities were required
to be licensed (Bureau of the Census 1914), but many were not.
Public institutions sought to lower their censuses even as state hospital populations
grew and patients had progressively longer lengths of stay (Grob 1983); private facil-
ities sought patients to maximize their occupancy rates. A fundamental criticism of
private facilities was the inherent conflict of interest of the proprietor: “It is not for the
interest of the proprietor of a private asylum to cure his patients, and hence they may
not make an honest effort to promote their cure” (Parsons 1881, pp. 578–579). Private
facilities advertised and were not infrequently endorsed in professional journal editori-
als (“Two Homes for the Nervous and Insane” 1880). Advertising by private facilities
and by physicians was frequent enough that a code for professional advertising was
proposed in 1894 (“Provision for Professional Advertising in the Code” 1894).
By the 1880s, some states (e.g., Connecticut, Indiana, Maryland, Massachusetts,
New York, Pennsylvania, Rhode Island, Wisconsin) permitted the commitment of in-
sane persons to private facilities (Board of State Commissioners of Public Charities of
the State of Illinois 1885). As a way of relieving crowding at state hospitals, proposals
were put forward to “furlough” patients from state hospitals to private facilities in an
early version of contemporary “step-down procedures” (“Insane Hospital Annexes”
1880). Similar procedures were recently used in the state of Vermont, for example, for
the same reason.
Private hospitals, in contrast to public hospitals, could become quite luxurious.
Long Island House, in Amityville, New York, built a small cottage consisting of a sit-
ting room, bedroom, bathroom, and clothespress for a single patient in 1900 (“Long
Island House, Amityville, NY” 1900). Upham House, at McLean Asylum, included
FIGURE 1–12. Utica State Hospital.

Source. Courtesy of American Psychiatric Association Archives, Washington, D.C./National Library of
Medicine, Bethesda, Maryland.
nine suites, each containing a sitting room, bedroom, and bathroom; the house had
two private halls, reception rooms, a dining room, a billiard room, and a Turkish bath
(“The McLean Asylum for the Insane” 1893).
Greater resources led to remarkably favorable staffing ratios at private hospitals.
In the 1850s, Friends Asylum had an attendant for every six patients (“The Asylum
near Frankford, in Pennsylvania” 1851). Both Kirkbride (Pennsylvania Hospital for
the Insane 1850) and Jarvis (Association of Medical Superintendents of American In-
stitutions for the Insane 1853) described private attendants for every patient.
In 1851, John Butler (Figure 1–13), superintendent of the Hartford Retreat, noted
both the importance of “mental occupations and amusements” and the fact that many
asylums were lacking in the provision of these (Connecticut 1855). He repeated this
theme 35 years later (Butler 1886). In this early period of inpatient psychiatry, the pri-
vate facilities offered a remarkable array of activities for amusement and recreation,
including baseball, boating, bowling, calisthenics and gymnasiums, concerts, cook-
ing instruction, croquet, exhibitions, fishing, French lessons, golf, horseback riding,
lantern slide shows, lectures, medicine ball, museums, pleasure grounds, reading
rooms, skating, squash and tennis, stereoscopic views, tea parties, and wood carving
(“At the Pennsylvania Hospital for the Insane” 1852; “Gymnasium for the Insane”
1897; Pennsylvania Hospital for the Insane 1854). Public hospitals did less well in pro-
viding amusements but had better developed work programs that were thought to be
important to patients’ recovery.
Despite their efforts, private hospitals suffered from the “premature removal of pa-
tients” (Butler Hospital for the Insane 1856; “Dr. Butler of the Hartford Retreat for the
Insane” 1851; Pennsylvania Hospital for the Insane 1854; Sawyer 1879; Stokes 1851).
In 1851, Butler expressed concerns about the outcomes for patients who left the asylum
FIGURE 1–13. John S. Butler.

too soon: “Many have relapsed into an incurable state, while others remain half-crazed
or nervous invalids, and will probably remain so for life” (“Dr. Butler of the Hartford
Retreat for the Insane” 1851, p. 187). Isaac Ray of Butler Hospital (Figure 1–14) called
the premature withdrawal of patients “a most disheartening experience of our call-
ing” (Butler Hospital for the Insane 1856, p. 252). The superintendents of the private
facilities during this era (unlike those of public facilities) did not have the authority
to hold patients if family or friends insisted on their discharge (Stokes 1851). Some pa-
tients certainly left private facilities because of the inability to pay for further care
(Butler Hospital for the Insane 1856; Stokes 1851). Ray, perhaps somewhat cavalierly,
exclaimed, “We may indeed be shocked by this balancing of reason, God’s greatest
gift to man, with a paltry sum of money” (Butler Hospital for the Insane 1856, p. 282).
Other patients were removed because family and friends were “impatient for the re-
sults” or unwilling to wait until “the disease is fully eradicated” (Stokes 1851, p. 211). Pa-
tients who were prematurely discharged from private facilities were not infrequently
subsequently admitted to public facilities, because of the lack of an available bed,
inadequate financial resources, or the patient’s “unmanageable” behavior (Sawyer
1879). Others were concerned that patients discharged before they were medically
ready could be a danger to the community from acts of violence (Sawyer 1879).
By the end of the 1880s, there was recognition that “the unparalleled progress in
neurology, cerebral anatomy, physiology, pathology, and localization of function has
enlarged the horizon of our knowledge of disease and of the action of causes” (Andrews
FIGURE 1–14. Isaac Ray.

1887, p. 199). This progress “furnished a scientific and positive basis for treatment in
many cases of insanity which before was unattainable” (Andrews 1887, p. 199). Inpa-
tient treatments near the end of the nineteenth century included electricity, massage,
new medications and more rational prescribing, and oophorectomy (Andrews 1887);
enforced rest (Sinkler 1892); hydrotherapy (Niles 1899); and physical training (Chan-
ning 1889). These approaches, although suspect in retrospect, represented significant
advances for inpatient psychiatric treatment.
Hospitals devised new record-keeping systems to facilitate research (“McLean
Hospital, Waverly” 1900); expanded clinical pathological laboratories (“Psychiatry at
the Sheppard and Enoch Pratt Hospital” 1901); focused on such diseases as dementia
praecox and syphilis (“Bloomingdale Hospital, White Plains” 1913); and hired physi-
cians with research interests and expertise (“McLean Hospital, Waverly” 1900). The
new focus on research is highlighted in a statement by Edward Brush, first superin-
tendent of Sheppard and Enoch Pratt Hospital: “The most important function [of a
hospital] is to study disease, its causes, progress, processes, termination and preven-
tion” (“Psychiatry at the Sheppard and Enoch Pratt Hospital” 1901, p. 554).
In the end, however, it was Thomas Kirkbride (Figure 1–15) who made the most pro-
phetic commentary for many of these hospitals: “So in regard to the support of hospitals
for the insane, it will be a sad day for these institutions, and still sadder for the patients
in them, when the rivalry of hospitals and their officers shall be, rather to discover for
how little their inmates can be kept, than to secure what is best, and most thoroughly
promotes the great objects for which they were established” (Kirkbride 1875, p. 99).
FIGURE 1–15. Thomas Kirkbride.

The Middle Period (1921–1970)

Changes in American psychiatry between 1921 and 1970 were dramatic and far-reaching.
In terms of treatment modalities, psychoanalysis was introduced to the inpatient set-
ting in the 1920s. The 1930s witnessed the introduction of the somatic treatments: in-
sulin coma, metrazol shock, and electroshock therapy (Kalinowski and Hoch 1946).
In the 1940s, attention was directed to establishing milieu therapy, in which “all as-
pects of the patient’s life in the hospital were viewed as part of treatment” (Robbins
1966). In the 1950s, the introduction of the first antipsychotic medication,
chlorpromazine, fundamentally altered inpatient psychiatry (Smith 1955). And in
the 1960s, initial attempts to understand the mechanism of action of psychotropic
drugs (Snyder et al. 1970) spurred efforts that to this day shape our pharmacological
armamentarium.
Alternatives to psychiatric inpatient treatment, such as the day hospital, were ini-
tiated and promoted. Claims of being the “first day hospital in North America” were
made by hospital staff in Boston, Montreal, and Topeka, Kansas. Psychiatric inpatient
treatment based in general hospitals developed during this period (American Hospi-
tal Association 1970; Glasscote and Kanno 1965). Psychiatrists attempted to improve
diagnostic validity and reliability (Jackson 1970) and to promulgate standards for in-
patient psychiatric facilities (American Psychiatric Association 1969). New concepts,
such as the rights of mental patients, emerged (Birnbaum 1960), and old, nineteenth-
Another random document with
no related content on Scribd:
“So long as you deliberately refuse to help in any way a man who
(you have every reason to know) possesses more of the
righteousness of God than yourself, (when you have ample means to
do so,) how can you be said to ‘do the will of your Father which is in
Heaven’? or how can you expect to receive understanding to ‘know
of the doctrine’ of the Saviour, (or of my doctrine,) ‘whether it be of
God, or whether I speak of myself’? If you possessed a genuine
‘faith,’ you would exercise humanity towards such a man as myself,
and leave the result with God; and not presumptuously decide that it
was ‘wrong’ to relieve ‘a righteous man’ in distress, lest [112]you
should encourage him in delusions which you choose to suppose
him to be labouring under.
“People seem to suppose that it is the Saviour who will judge the
world, if any one does. He distinctly declares that He will not. ‘If any
one hear my words, and believe not, I judge him not; for I came not
to judge the world, but to save the world. He that rejecteth me, and
receiveth not my words, hath one that judgeth him: the word that I
have spoken, the same shall judge him in the last day.’ John xii. 47,
48 ↗️. I represent that ‘WORD’ which the Saviour spoke, and I have
already judged, and condemned, this country, and the United States,
in particular; and Christendom, and the World in general. I have for
twenty years been a preacher of ‘the Righteousness of God’ to this
generation (as Noah was for a hundred years to his generation), and
I have proved by actual experiment that none among the men of this
generation can be induced to ‘enter the kingdom of heaven’ until the
predicted ‘time of trouble, such as was not since there was a nation,’
comes suddenly, and compels those who are ready to enter the
kingdom of God, to do so at once; and I know not how soon after I
leave this country the ‘trouble’ will come; perhaps immediately,
perhaps in about a year’s time; but come it must; and the sooner it
comes, the sooner it will be over, I suppose.
“Yours faithfully.”
The following specimen of the kind of letters which the “judge of the
United States in particular, and the World in general,” leaves the
people favoured by his judgment to send to his friends, may as well
supplement his own letter:—
“Mr. (J. of U.S. in p. and the W. in g.)’s name will, I trust, excuse me
to you for writing; but my house entirely failed me, and I, with my
child, are now really in great want. I write [113]trusting that, after your
former kindness to me, you will feel disposed to send me a little
assistance.
“I would not have written, but I am seriously in need.
“Please address to me,” etc.
Whether, however, the judge of the world in general errs most in

expecting me to pay the necessary twopences to his hosts, or the
world in general itself, in expecting me to pay necessary twopences
to its old servants when it has no more need of them, may be
perhaps questionable. Here is a paragraph cut out of an application
for an hospital vote, which I received the other day:—
Mr. A., aged seventy-one, has been a subscriber to the Pension

Fund forty-five years, the Almshouse Fund eighteen years, and the
Orphan Fund four years. He is now, in consequence of his advanced
age, and the infirmities attendant on a dislocated shoulder, asthma,
and failing sight, incapable of earning sufficient for a subsistence for
himself and wife, who is afflicted with chronic rheumatic gout. He
was apprenticed to Mr. B., and has worked for Mr. C. D. forty years,
and his earnings at present are very small.
Next, here is a piece of a letter disclosing another curious form of
modern distress, in which the masters and mistresses become
dependent for timely aid on their servants. This is at least as old,
however, as Miss Edgeworth’s time; I think the custom is referred to
at the toilette of Miss Georgiana Falconer in ‘Patronage.’
“Every day makes me bitterly believe more and more what you say
about the wickedness of working by fire and steam, and the harm
and insidious sapping of true life that comes from large mills and all
that is connected with them. One of my servants told my sister to-
day (with an apology) that her mother [114]had told her in her letter to
ask me if I would sell her my children’s old clothes, etc.—that indeed
many ladies did—her mother had often bought things. Oh! it made
me feel horrible. We try to buy strong clothes, and mend them to the
last, and then sometimes give them away; but selling clothes to poor
people seems to me dreadful. I never thought ladies and gentlemen
would sell their clothes even to shops—till we came to live here, and
happened to know of its being done. It surely must be wrong and
bad, or I should not feel something in me speaking so strongly
against it, as mean and unholy.”
A piece of country gossip on bees and birds, with a humiliating

passage about my own Coniston country, may refresh us a little after
dwelling on these serious topics:—
“A humble cow is I fancy more properly a humbled cow—it is so

called in Durham—a cow whose horn is no longer set up on high. A
humble or bumble bee is there called a ‘bumbler.’ To bumble in
Durham means to go buzzing about; a fussy man would be called a
great bumbler. But don’t believe it has no sting: it can sting worse
than a honey bee, and all but as badly as a wasp. They used to tell
us as children that ‘bumblers’ did not sting, but I know from
experience that they do. We used as children to feel that we knew
that the little yellow mason bee (?) did not sting, but I have no true
knowledge on that point. Do you care to have the common village
names of birds? I am afraid I can only remember one or two, but
they are universally used in the north.
“The wren which makes the hanging nest lined with feathers is called
the feather poke; yellow-hammer, yellow-yowley; golden-crested
wren, Christian wren; white-throat, Nanny white-throat; hedge-
sparrow, Dicky Diky. I could find more if you cared for them. To wind
up, I will send you an anecdote I find among father’s writings, and
which refers to your country. He is speaking [115]of some time early in
1800. ‘Cock-fighting was then in all its glory. When I was in the
neighbourhood of Ulverston, in 18—, 8 I was told that about the time
of which I am writing, a grave ecclesiastical question had been
settled by an appeal to a battle with cocks. The chapelry of
Pennington was vacant, but there was a dispute who should present
a clerk to the vacant benefice,—the vicar of Ulverston, the mother-
church, the church-wardens, the four-and-twenty, or the parishioners
at large,—and recourse was had to a Welsh Main.’ ”
Finally, the following letter is worth preserving. It succinctly states the

impression on the minds of the majority of booksellers that they
ought to be able to oblige their customers at my expense. Perhaps in
time, the customers may oblige the booksellers by paying them
something for their trouble, openly, instead of insisting on not paying
them anything unless they don’t know how much it is.
“Mr. George Allen.
Sir,—We will thank you to send us Ruskin’s
Aratra Pentelici £0 19 0
The Eagle’s Nest 0 96
Relations between Angelo and Tintoret 0 10
£1 9 6
And continue Account next year Fors Clavigera 0 7 0
Cheque enclosed. £1 16 6
“It cannot be too frequently referred to by the trade,—the

unjustifiable mode Ruskin has adopted in the sale of his books. [116]It
may be profitable to you (as we hope it is), but to the general trade it
is nothing but a swindle. Our customer, for instance (whom we
cannot afford to disoblige), pays us for this order just £1 16s. 6d.;
and we must come back on him for expense of remitting, else we
shall lose by the transaction.
“Your obedient Servant.”
[117]
Frightened, (I hear it was guessed in a gossiping newspaper,) by the Shipton

1 accident, and disgusted afterwards by unexpected expenses. The ingenious
British public cannot conceive of anybody’s estimating danger before accidents as
well as after them, or amusing himself by driving from one place to another,
instead of round the Park. There was some grain of truth in the important rumour,
however. I have posted, in early days, up and down England (and some other
countries) not once nor twice; and I grumbled, in Yorkshire, at being charged
twenty-pence instead of eighteen-pence a mile. But the pace was good, where any
trace of roads remained under casual outcasting of cinders and brickbats. ↑
“Our Lady’s,” doubtless, once. ↑
2
I include in my general term ‘mob,’ lords, squires, clergy, parish beadles, and
3 all other states and conditions of men concerned in the proceedings
described. ↑
They are round at the end, but do not taper. ↑
4
An Indian one, patiently investigated for me by Mr. Burgess, was fastened
5 with glue which entirely defied cold water, and yielded only to the kettle. ↑
She bites them round the edge roughly enough; but pushes them down with a
6 tucked-up rim, quite tight, like the first covering of a pot of preserve. ↑
Or in old wood. ↑
7
He does not give the date. ↑
8
[Contents]
FORS CLAVIGERA.
LETTER LIII.
Brantwood, Good Friday, 1875.
I am ashamed to go on with my own history to-day; for though, as

already seen, I was not wholly unacquainted with the practice of
fasting, at times of the year when it was not customary with Papists,
our Lent became to us a kind of moonlight Christmas, and season of
reflected and soft festivity. For our strictly Protestant habits of mind
rendering us independent of absolution, on Shrove Tuesday we were
chiefly occupied in the preparation of pancakes,—my nurse being
dominant on that day over the cook in all things, her especially
nutritive art of browning, and fine legerdemain in turning, pancakes,
being recognised as inimitable. The interest of Ash-Wednesday was
mainly—whether the bits of egg should be large or small in the egg-
sauce;—nor do I recollect having any ideas connected with the day’s
name, until I was puzzled by the French of it when I fell in love with a
Roman Catholic French girl, as hereafter to be related:—only, by the
way, let me note, as I chance now to remember, two others of my
[118]main occupations of an exciting character in Hunter Street:
watching, namely, the dustmen clear out the ash-hole, and the
coalmen fill the coal-cellar through the hole in the pavement, which
soon became to me, when surrounded by its cone of débris, a
sublime representation of the crater of a volcanic mountain. Of these
imaginative delights I have no room to speak in this Fors; nor of the
debates which used to be held for the two or three days preceding
Good Friday, whether the hot-cross-buns should be plain, or have
carraway seeds in them. For, my nurse not being here to provide any
such dainties for me, and the black-plague wind which has now
darkened the spring for five years, 1 veiling all the hills with sullen
cloud, I am neither in a cheerful nor a religious state of mind; and am
too much in the temper of the disciples who forsook Him, and fled, to
be able to do justice to the childish innocence of belief, which, in my
mother, was too constant to need resuscitation, or take new colour,
from fast or festival.
Yet it is only by her help, to-day, that I am able to do a piece of work

required of me by the letter printed in the second article of this
month’s correspondence. It is from a man of great worth,
conscientiousness, and kindliness; but is yet so perfectly expressive
of the irreverence, and incapacity of admiration, which [119]maintain
and, in great part, constitute, the modern liberal temper, that it makes
me feel, more than anything I ever yet met with in human words, how
much I owe to my mother for having so exercised me in the
Scriptures as to make me grasp them in what my correspondent
would call their ‘concrete whole’; and above all, taught me to
reverence them, as transcending all thought, and ordaining all
conduct.
This she effected, not by her own sayings or personal authority; but
simply by compelling me to read the book thoroughly, for myself. As
soon as I was able to read with fluency, she began a course of Bible
work with me, which never ceased till I went to Oxford. She read
alternate verses with me, watching, at first, every intonation of my
voice, and correcting the false ones, till she made me understand the
verse, if within my reach, rightly, and energetically. It might be
beyond me altogether; that she did not care about; but she made
sure that as soon as I got hold of it at all, I should get hold of it by the
right end.
In this way she began with the first verse of Genesis and went
straight through to the last verse of the Apocalypse; hard names,
numbers, Levitical law, and all; and began again at Genesis the next
day; if a name was hard, the better the exercise in pronunciation,—if
a chapter was tiresome, the better lesson in patience,—if loathsome,
the better lesson in faith that there was some use in its being so
outspoken. After [120]our chapters, (from two to three a day,
according to their length, the first thing after breakfast, and no
interruption from servants allowed,—none from visitors, who either
joined in the reading or had to stay upstairs,—and none from any
visitings or excursions, except real travelling,) I had to learn a few
verses by heart, or repeat, to make sure I had not lost, something of
what was already known; and, with the chapters above enumerated,
(Letter XLII ↗️. 2), I had to learn the whole body of the fine old
Scottish paraphrases, which are good, melodious, and forceful
verse; and to which, together with the Bible itself, I owe the first
cultivation of my ear in sound.
It is strange that of all the pieces of the Bible which my mother thus
taught me, that which cost me most to learn, and which was, to my
child’s mind, chiefly repulsive—the 119th Psalm—has now become
of all the most precious to me, in its overflowing and glorious passion
of love for the Law of God: “Oh, how love I Thy law! it is my
meditation all the day; I have refrained my feet from every evil way,
that I might keep Thy word”;—as opposed to the ever-echoing words
of the modern money-loving fool: “Oh, how hate I thy law! it is my
abomination all the day; my feet are swift in running to mischief, and
I have done all the [121]things I ought not to have done, and left
undone all I ought to have done; have mercy upon me, miserable
sinner,—and grant that I, worthily lamenting my sins and
acknowledging my wretchedness, may obtain of Thee, the God of all
mercy, perfect remission and forgiveness,—and give me my long
purse here and my eternal Paradise there, all together, for Christ’s
sake, to whom, with Thee and the Holy Ghost, be all honour and
glory,” etc. And the letter of my liberal correspondent, pointing out, in
the defence of usury (of which he imagines himself acquainted with
the history!) how the Son of David hit his father in the exactly weak
place, puts it in my mind at once to state some principles respecting
the use of the Bible as a code of law, which are vital to the action of
the St. George’s Company in obedience to it.
All the teaching of God, and of the nature He formed round Man, is
not only mysterious, but, if received with any warp of mind,
deceptive, and intentionally deceptive. The distinct and repeated
assertions of this in the conduct and words of Christ are the most
wonderful things, it seems to me, and the most terrible, in all the
recorded action of the wisdom of Heaven. “To you” (His disciples) “it
is given to know the mysteries of the kingdom,—but to others, in
parables, that, hearing, they might not understand.” Now this is
written not for the twelve only, but for all disciples of Christ in all
ages,—of whom the sign is one and unmistakable: “They have
forsaken all that they [122]have”; while those who “say they are Jews
and are not, but do lie,” or who say they are Christians and are not,
but do lie, try to compromise with Christ,—to give Him a part, and
keep back a part;—this being the Lie of lies, the Ananias lie, visited
always with spiritual death. 3
There is a curious chapter on almsgiving, by Miss Yonge, in one of

the late numbers of the “Monthly Packet”, (a good magazine, though,
on the whole, and full of nice writing,) which announces to her
disciples, that “at least the tenth of their income is God’s part.” Now,
in the name of the Devil, and of Baal to back him,—are nine parts,
then, of all we have—our own? or theirs? The tithe may, indeed, be
set aside for some special purpose—for the maintenance of a
priesthood—or as by the St. George’s Company, for distant labour,
or any other purpose out of their own immediate range of action. But
to the Charity or Alms of men—to Love, and to the God of Love, all
their substance is due—and all their strength—and all their time.
That is the first commandment: Thou shalt love the Lord with all thy
strength and soul. Yea, says the false disciple—but not with all my
money. And of these it is written, after that thirty-third verse of Luke
xiv. ↗️: “Salt is good; but if the salt have lost his savour, it is neither
fit for the land nor the dunghill. He that hath ears to hear, let him
hear.” [123]
Now in Holbein’s great sermon against wealth, the engraving, in the

Dance of Death, of the miser and beggar, he chose for his text the
verse: “He that stoppeth his ears at the cry of the poor, he also shall
cry himself, and shall not be heard.” And he shows that the ear is
thus deafened by being filled with a murmuring of its own: and how
the ear thus becomes only as a twisted shell, with the sound of the
far-away ocean of Hell in it for ever, he teaches us, in the figure of
the fiend which I engraved for you in the seventh of these letters, 4
abortive, fingerless, contemptible, mechanical, incapable;—blowing
the winds of death out of its small machine: Behold, this is your God,
you modern Israel, which has brought you up out of the land of Egypt
in which your fathers toiled for bread with their not abortive hands;
and set your feet in the large room, of Usury, and in the broad road
to Death!
Now the moment that the Mammon devil gets his bellows put in
men’s ears,—however innocent they may be, however free from
actual stain of avarice, they become literally deaf to the teaching of
true and noble men. My correspondent imagines himself to have
read Shakespeare and Goethe;—he cannot understand a sentence
of them, or he would have known the meaning of the Merchant of
Venice, 5 and of the vision of Plutus, [124]and speech of
Mephistopheles on the Emperor’s paper-money 6 in the second part
of Faust, and of the continual under-current of similar teaching in it,
from its opening in the mountain sunrise, presently commented on
by the Astrologer, under the prompting of Mephistopheles,—“the Sun
itself is pure Gold,”—to the ditch-and-grave-digging scene of its
close. He cannot read Xenophon, nor Lucian,—nor Plato, nor
Horace, nor [125]Pope,—nor Homer, nor Chaucer—nor Moses, nor
David. All these are mere voices of the Night to him; the bought
bellows-blower of the “Times” is the only piper who is in tune to his
ear.
And the woe of it is that all the curse comes on him merely as one of
the unhappy modern mob, infected by the rest; for he is himself
thoroughly honest, simple-hearted, and upright: only mischance
made him take up literature as a means of life; and so brought him
necessarily into all the elements of modern insolent thought: and
now, though David and Solomon, Noah, Daniel, and Job, altogether
say one thing, and the correspondent of the “Times” another, it is
David, Solomon, and Daniel who are Narrs to him.
Now the Parables of the New Testament are so constructed that to

men in this insolent temper, they are necessarily misleading. It is
very awful that it should be so; but that is the fact. Why prayer should
be taught by the story of the unjust judge; use of present opportunity
by that of the unjust steward; and use of the gifts of God by that of
the hard man who reaped where he had not sown,—there is no
human creature wise enough to know;—but there are the traps set;
and every slack judge, cheating servant, and gnawing usurer may, if
he will, approve himself in these.
“Thou knewest that I was a hard man.” Yes—and if God were also a
hard God, and reaped where He had not sown—the conclusion
would be true that earthly [126]usury was right. But which of God’s
gifts to us are not His own?
The meaning of the parable, heard with ears unbesotted, is this:

—“You, among hard and unjust men, yet suffer their claim to the
return of what they never gave; you suffer them to reap, where they
have not strawed.—But to me, the Just Lord of your life—whose is
the breath in your nostrils, whose the fire in your blood, who gave
you light and thought, and the fruit of earth and the dew of heaven,—
to me, of all this gift, will you return no fruit but only the dust of your
bodies, and the wreck of your souls?”
Nevertheless, the Parables have still their living use, as well as their
danger; but the Psalter has become practically dead; and the form of
repeating it in the daily service only deadens the phrases of it by
familiarity. I have occasion to-day, before going on with any work for
Agnes, to dwell on another piece of this writing of the father of Christ,
—which, read in its full meaning, will be as new to us as the first-
heard song of a foreign land.
I will print it first in the Latin, and in the letters and form in which it
was read by our Christian sires. [127]
The Eight Psalm. Thirteenth Century Text. 7
Domine dominus noster q̄ m admirabile est nomen tuum in

universa terra. Quoniam elevata est magnificentia tua super
celos. Ex ore infantium t̄ lactentium p̄ fecisti laudem p̄ pter
inimicos tuos ut destruas inimicū t̄ ultorem. Quoniam videbo
celos tuos opera digitor. tuor. lunam t̄ stellas que tu fundasti
Quid est h̥̊ quod memor es ejus, aū filius h̥ ōis quia visitas
eum. Minuisti eum paulominus; ab angelis, gloria t̄ honore
coronasti eum t̄ cstituisti eum super opera manuum tuar.
Om̄ ia subjecisti sub pedibs ejus, oves t̄ boves univ̄ sas,
insuper t̄ pecora campi. Volucres celi t̄ pisces maris q̄
p̄ ambulant semitas maris. Domine dominus noster quam
admirabile est nomen tuum in univ̄ sa terra.
[128]
I translate literally; the Septuagint confirming the Vulgate in the
differences from our common rendering, several of which are
important.
“1. Oh Lord, our own Lord, how admirable is thy Name in all the
earth!
2. Because thy magnificence is set above the heavens.
3. Out of the mouth of children and sucklings thou hast perfected

praise, because of thine enemies, that thou mightest scatter the
enemy and avenger.
4. Since I see thy heavens, the work of thy fingers, the moon and the
stars which thou hast founded,
5. What is man that thou rememberest him, or the son of man, that
thou lookest on him?
6. Thou hast lessened him a little from the angels; thou hast crowned
him with glory and honour, and hast set him over all the works of thy
hands.
7. Thou hast put all things under his feet; sheep, and all oxen—and
the flocks of the plain.
8. The birds of the heaven and the fish of the sea, and all that walk in
the paths of the sea.
9. Oh Lord, our own Lord, how admirable is thy Name in all the
earth!”
Note in Verses 1 and 9.—Domine, Dominus noster; our own Lord;

Κύριε, ὁ Κύριος ἡμῶν; claiming thus the Fatherhood. The ‘Lord our
Governour’ of the Prayer Book entirely loses the meaning. How
admirable is Thy [129]Name! θαυμαστον, ‘wonderful,’ as in Isaiah,
“His name shall be called Wonderful, the Counsellor.” Again our
translation ‘excellent’ loses the meaning.
Verse 2.—Thy magnificence. Literally, ‘thy greatness in working’ (Gk.

μεγαλοπρέπεια—splendour in aspect), distinguished from mere
‘glory’ or greatness in fame.
Verse 3.—Sidney has it:
“From sucklings hath thy honour sprung,

Thy force hath flowed from babies’ tongue.”
The meaning of this difficult verse is given by implication in Matt. xxi.

16 ↗️. And again, that verse, like all the other great teachings of
Christ, is open to a terrific misinterpretation;—namely, the popular
evangelical one, that children should be teachers and preachers,—
(“cheering mother, cheering father, from the Bible true”). The lovely
meaning of the words of Christ, which this vile error hides, is that
children, remaining children, and uttering, out of their own hearts,
such things as their Maker puts there, are pure in sight, and perfect
in praise. 8
Verse 4.—The moon and the stars which thou hast founded
—‘fundasti’—ἐθεμελίωσας. It is much more than ‘ordained’: the idea
of stable placing in space being the main one in David’s mind. And it
remains to this day [130]the wonder of wonders in all wise men’s
minds. The earth swings round the sun,—yes, but what holds the
sun? The sun swings round something else. Be it so,—then, what
else?
Sidney:—
“When I upon the heavens do look,
Which all from thee their essence took,
When moon and stars my thought beholdeth,
Whose life no life but of thee holdeth.”
Verse 5.—That thou lookest on him; ἐπισκέπτῃ αυτον, ‘art a bishop

to him.’ The Greek word is the same in the verse “I was sick and ye
visited me.”
Verse 6.—Thou hast lessened him;—perhaps better, thou hast made

him but by a little, less, than the angels: ἠλάττωσας αὐτὸν βραχύ τι.
The inferiority is not of present position merely, but of scale in being.
Verse 7.—Sheep, and all oxen, and the flocks of the plain: κτήνη τοῦ
πεδίον. Beasts for service in the plain, traversing great spaces,—
camel and horse. ‘Pecora,’ in Vulgate, includes all ‘pecunia,’ or
property in animals.
Verse 8.—In the Greek, “that walk the paths of the seas” is only an
added description of fish, but the meaning of it is without doubt to
give an expanded sense—a generalization of fish, so as to include
the whale, seal, tortoise, and their like. Neither whales nor seals,
however, from what I hear of modern fishing, are [131]likely to walk
the paths of the sea much longer; and Sidney’s verse becomes mere
satire:—
“The bird, free burgesse of the aire,

The fish, of sea the native heire,
And what things els of waters traceth
The unworn pathes, his rule embraceth.
Oh Lord, that rul’st our mortal lyne,
How through the world thy name doth shine!”
These being, as far as I can trace them, the literal meanings of each
verse, the entire purport of the psalm is that the Name, or
knowledge, of God was admirable to David, and the power and
kingship of God recognizable to him, through the power and kingship
of man, His vicegerent on the earth, as the angels are in heavenly
places. And that final purport of the psalm is evermore infallibly true,
—namely, that when men rule the earth rightly, and feel the power of
their own souls over it, and its creatures, as a beneficent and
authoritative one, they recognise the power of higher spirits also; and
the Name of God becomes ‘hallowed’ to them, admirable and
wonderful; but if they abuse the earth and its creatures, and become
mere contentious brutes upon it, instead of order-commanding kings,
the Name of God ceases to be admirable to them, and His power to
be felt; and gradually, license and ignorance prevailing together,
even what memories of law or Deity remain to them become
intolerable; and in the exact [132]contrary to David’s—“My soul
thirsteth for God, for the Living God; when shall I come and appear
before God?”—you have the consummated desire and conclusive
utterance of the modern republican:
“S’il y avait un Dieu, il faudrait le fusiller.”
Now, whatever chemical or anatomical facts may appear to our

present scientific intelligences, inconsistent with the Life of God, the
historical fact is that no happiness nor power has ever been attained
by human creatures unless in that thirst for the presence of a Divine
King; and that nothing but weakness, misery, and death have ever
resulted from the desire to destroy their King, and to have thieves
and murderers released to them instead. Also this fact is historically
certain,—that the Life of God is not to be discovered by reasoning,
but by obeying; that on doing what is plainly ordered, the wisdom
and presence of the Orderer become manifest; that only so His way
can be known on earth, and His saving health among all nations;
and that on disobedience always follows darkness, the forerunner of
death.
And now for corollary on the eighth Psalm, read the first and second
of Hebrews, and to the twelfth verse of the third, slowly; fitting the
verse of the psalm—“lunam et stellas quæ tu fundasti,” with “Thou,
Lord, in the beginning hast laid the foundations of the earth”; and
then noting how the subjection which is merely of the lower creature,
in the psalm, becomes the subjection of [133]all things, and at last of
death itself, in the victory foretold to those who are faithful to their
Captain, made perfect through sufferings; their Faith, observe,
consisting primarily in closer and more constant obedience than the
Mosaic law required,—“For if the word spoken by angels was
stedfast, and every transgression and disobedience received its just
recompence of reward, how shall we escape, if we neglect so great
salvation?” The full argument is: “Moses, with but a little salvation,
saved you from earthly bondage, and brought you to an earthly land
of life; Christ, with a great salvation, saves you from soul bondage,
and brings you to an eternal land of life; but, if he who despised the
little salvation, and its lax law, (left lax because of the hardness of
your hearts,) died without mercy, how shall we escape, if now, with
hearts of flesh, we despise so great salvation, refuse the Eternal
Land of Promise, and break the stricter and relaxless law of Christian
desert-pilgrimage?” And if these threatenings and promises still
remain obscure to us, it is only because we have resolutely refused
to obey the orders which were not obscure, and quenched the Spirit
which was already given. How far the world around us may be yet
beyond our control, only because a curse has been brought upon it
by our sloth and infidelity, none of us can tell; still less may we dare
either to praise or accuse our Master, for the state of the creation
over which He appointed us kings, and in which we have [134]chosen
to live as swine. One thing we know, or may know, if we will,—that
the heart and conscience of man are divine; that in his perception of

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Textbook of Hospital Psychiatry 2nd

Edition Harsh K. Trivedi

Textbook of Community Psychiatry American Association

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The Massachusetts General Hospital Handbook of

Comprehensive Textbook of AIDS Psychiatry A Paradigm

Textbook of Medical Psychiatry 1st Edition Edited By

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Microeconometrics Using Stata Cross Sectional and Panel

About the Editors

Steven S. Sharfstein, M.D., M.P.A.

Everything done for the comfort of the patient...

No patient to be confined below ground...

To carry forward and improve the ameliorated system

If five persons were returned to health and reason,

1 History of Hospital Psychiatry . . . . . . . . . . .1

2 The Child Unit . . . . . . . . . . . . . . . . . . . . . .47

3 The Adolescent Unit . . . . . . . . . . . . . . . . . .67

4 The Adult Crisis Stabilization Unit . . . . . . .87

Units by Diagnostic Cohort

6 The Developmental Disabilities

7 The Eating Disorders Unit . . . . . . . . . . . . 183

8 The Forensic Unit . . . . . . . . . . . . . . . . . . 211

9 The Psychotic Disorders Unit . . . . . . . . . 229

10 The Substance Use Disorders

11 The State Hospital . . . . . . . . . . . . . . . . . .291

12 The Veterans Hospital . . . . . . . . . . . . . . .311

13 Community Mental Health and Hospital-

14 Residential Treatment for Children and

15 Residential Intensive Psychodynamic

17 Administration and Leadership . . . . . . . . 411

18 Financing of Care . . . . . . . . . . . . . . . . . . 433

19 Quality, Measurement-Based Care, and

20 Risk Management . . . . . . . . . . . . . . . . . . 463

22 Lean and Operational Excellence . . . . . . .503

23 Architecture and Thoughtful Design . . . . .517

24 Psychiatrists, Psychiatric Nurse

25 Psychiatric Mental Health Nursing . . . . . .547

26 Social Work and Rehabilitation

28 From Within: A Consumer Perspective on

29 Collaborative Care and Emerging

30 The Future of Hospital Psychiatry . . . . . . 625

Benedicto Borja, M.D.

John J. Boronow, M.D.

Harry A. Brandt, M.D.

Kathryn Burns, R.N., M.S.N.

Nathaniel Clark, M.D.

Steven F. Crawford, M.D.

Antonio DePaolo, Ph.D.

Charles C. Dike, M.D., M.P.H., FRCPsych

Lisa B. Dixon, M.D., M.P.H.

Kenneth S. Duckworth, M.D.

Carrie Etheridge, LCSW-C

Thomas Flis, M.S.

Gregory Gattman, FACHE

Jeffrey L. Geller, M.D., M.P.H.

Thomas Glenn, M.S.F.