Book Review: Unlocking the Doors

It is fortunate that George Leader, who was Governor of Pennsylvania from 1955 to 1959, has recorded the history of one of his important contemporaries, Harry Shapiro. Shapiro was a politician who saw injustice against people whom were hidden from most of society, the mentally ill, realized they deserved far better treatment then they were receiving, and devoted his political and professional energies toward successfully changing the way the mentally ill were treated and improving their lives. How this was achieved forms the basis of this book.

The history of how we treated the mentally ill has not been pleasant. Much ignorance and societal desires to remove the mentally ill from sight has been what has guided mental health policies. Pennsylvania has historically been a leader in mental health treatment, from Pennsylvania Hospital in the 1770s becoming the first state funded hospital to accept extreme cases of mental illness (less extreme cases were imprisoned or confined). Back then, mechanical restraints were considered as part of cutting edge treatment practices. In the 19th century, Pennsylvanian Benjamin Rush conducted scientific research in mental illness and, while many of his treatments since have been found to have been ineffective or even made matters worse, at least he introduced the approach of searching for what might work. The state legislature approved the first state funded facility specifically for mental illness in 1841, yet the project was terminated when patronage and political waste depleted funds necessary for the actual project. A report authored by Dorothy Dix about the abuse, unsanitary conditions, and chaining of the mentally ill in various Pennsylvania facilities led the legislature to approve an asylum. The State Lunatic Hospital opened outside Harrisburg in 1851. A Philadelphian, Thomas Story Kirkbride, published research on the various levels of mental illness and the need for “moral treatment” of patients. The legislature then approved several laws on mental health, including creating treatment guidelines according to Kirkbride’s recommendations and providing mental health patients with the right to legal counsel. The 20th century found that practices including lobotomies, shock therapy, and placing violent patients into insulin comas were common,

When the Leader Administration took office, they found most mental health facilities were actually holders of patronage workers who were unskilled for mental health purposes. Their salaries were such large portions of facility budgets that building repairs were often neglected as unaffordable. Patients resided in officially condemned buildings. The deplorable conditions found enraged State Senator Harry Shapiro. When Shapiro was denied entry to inspect one mental health building, he forced his way in and saw the shocking conditions firsthand. There were severe shortages of professional staff to treat patients and patients lived in overcrowded residences. By 1955, the number of patients in state mental institutions was at its historical peak of just under 50,000. A patient then received only an average of five hours of psychotherapy per year.

Governor Leader appointed Harry Shapiro as Welfare Secretary, which included the Mental Health System. Shapiro hired experts from the American Psychiatric Association to study Pennsylvania’s system and to make recommendations. What Shapiro learned and then adopted were national recruitment efforts to hire skilled personnel, to create individualized treatment programs for all patients, and where feasible to adopt efforts to enable some to return to society. Prior to this, many patients who entered the mental health system remained there for the rest of their lives.

Shapiro also fought to depoliticize the mental health system. Past practices of patients being on liquid diets while mental health patronage employees ate lobster and caviar ceased. Patronage employees were replaced and funds shifted towards hiring nurses, medical doctors, and psychiatrists.

Shapiro learned about mental health treatment practices in other countries. He saw how techniques such as group therapy and recreational activities were helpful and encouraged their use in Pennsylvania. Shapiro noted that patients are more apt to heal when in environments that encourage healing.

Children with mental health difficulties should be separated from adults, Shapiro decided. He created the first Children’s Services Bureau as well as the first facilities solely for children. He saw to it that over 110,000 mentally and physically challenged children were provided education. Governor Leader led a successful campaign for the mandatory education of handicapped children.

The author notes how the number of mental health patients has declined from 50,000 in the 1950s to about 2,000 today. He suggests there may be analogies from the mental health problems of the 1950s to the difficulties of the corrections facilities of today, noting that the number of people incarcerated has increased from 7,000 in the mid-1950s to over 40,000 today, The focus of this book, though, is on mental health. The appreciation provide to Harry Shapiro is well deserved and serves as an important indicator of how one dedicated public figure, backed by a supportive Governor along with a dedicated staff, can change an entire system for the better. Pennsylvania needs more George Leaders and Harry Shapiros.