Book Review

The Lives They Left Behind: Suitcases from a State Hospital Attic

N Engl J Med 2008; 359:876-877August 21, 2008

Article

The Lives They Left Behind: Suitcases from a State Hospital Attic
By Darby Penney and Peter Stastny. 205 pp., illustrated. New York, Bellevue Literary Press, 2008. $25. ISBN: 978-1-934137-07-9

When the Willard Psychiatric Center, overlooking Seneca Lake in upstate New York, closed in 1995, a curator from the New York State Museum in Albany roamed the grounds, looking from building to building to see if there were any artifacts worth keeping before the buildings were demolished. In the sheltered workshop building, off a steep staircase leading up to the attic, was a large room with a central corridor that separated rows of wooden racks filled with suitcases of all shapes and sizes — 427 of them — all belonging to former patients who had been admitted between 1900 and 1960. This was a treasure trove of lives lived and lost, as most patients came to the hospital but never left — spending their entire lives institutionalized, in custody, and forgotten.

The contents of the suitcases, which had been sitting silently for decades, ultimately saw the light of day when an exhibit mounted at the New York State Museum in 2004 attracted more than 300,000 visitors and drew much acclaim. Darby Penney, a national leader in the human rights movement for people with psychiatric disabilities, and Peter Stastny, a psychiatrist and documentary filmmaker, discovered in 10 of these suitcases the remnants of lives in the form of letters to loved ones, photographs, knickknacks, and other personal effects. Penney and Stastny reconstructed the histories and recovered the pasts of these patients, describing in devastating detail the grimness and hopelessness of their lives at Willard.

Contents of a Suitcase Belonging to a Female Patient at the Willard Psychiatric Center.

In its 126 years of operation, the Willard Psychiatric Center (known as the Willard Asylum from 1869 to 1890 and the Willard State Hospital from 1890 to the early 1970s) treated more than 50,000 people. It was a self-sufficient enclave with more than 600 acres of farm land, a greenhouse, a dairy, stables, chicken houses, and barns. Nearly all the facility's food was raised and processed on-site. There were industrial shops producing clothing, shoes, baskets, brooms, and soap; there were also laundries, bakeries, and kitchens. The hospital had a slaughterhouse, a brickworks, a blacksmith shop, a coal-fired power plant, and its own police force. Its operation relied on the unpaid labor of the patients, and it is clear from their case histories that after many of the acute symptoms of psychosis receded, these patients served as unpaid staff.

The suitcases contained numerous photographs, many of which are beautifully reproduced in this book. They bring to life the people who were forgotten and make clear that any approach to the care and treatment of those with severe and persistent mental illness must respect their humanity. The main moral lesson of this book is that long-term institutionalization for mental illness robs people of their lives and personhoods. A community-based treatment system must preserve the humanity of a person with mental illness by respecting the person's past even within the reality of a precarious present. The hope and promise of recovery require individualized attention in normalizing circumstances outside institutions.

This book should be required reading for anyone who struggles with the treatment of mental illness in community settings. The closure of large hospitals such as Willard has resulted in major public health problems among people with mental illness — many of whom are homeless or have been incarcerated — but a return to the long-term institutional care of the past is unthinkable. Now, instead of suitcases forgotten in large institutions, there are thousands of former state hospital patients and people with newly diagnosed mental illness wandering the streets. Despite many examples of excellent community programs, we have yet to adopt a comprehensive policy that consistently provides and funds humane treatment for the most seriously ill patients.

The authors point out these problems, but they can seem excessively negative when discussing some of the new medications that, when combined with psychosocial care, can make a real difference in helping to prevent relapses of psychotic illness. We need better medical and psychosocial treatments with adequate funding, with patients and families empowered to make choices, evaluate treatment providers, and provide peer-run services — so that 50 to 100 years from now, future generations will not discover painful relics of the deficiencies of the current era of psychiatric care.

Steven S. Sharfstein, M.D.
Sheppard Pratt Health System, Baltimore, MD 21218