History of the South Carolina Department of Mental Health
From the establishment of the South Carolina State Hospital over 175 years ago, to the beginning of community mental health services in the 1920's, to the evolution of a complex mental health care delivery system, South Carolina has achieved an impressive record in its efforts to meet the needs of its mentally ill citizens.
As far back as 1694 the Lord Proprietors of the Carolinas decreed that the indigent mentally ill should be cared for locally at public expense. In 1751 the colonial government similarly recognized the mental health needs of slaves. In 1762 the Fellowship Society of Charleston established an infirmary for the mentally ill. But it was not until the 1800s that the mental health movement received legislative attention at the state level.
According to legend, when Colonel Samuel Farrow, a member of the House of Representatives from Spartanburg County, traveled to Columbia to attend sessions of the legislature, he noticed a woman who was mentally distressed and apparently without adequate care. Her poor condition made an impact on him and spurred him on to engage the support of Major William Crafts, a brilliant orator and a member of the Senate from Charleston County.
The two men worked zealously to sensitize their fellow lawmakers to the needs of the mentally ill, and on December 20, 1821, the South Carolina State Legislature passed a statute-at-large approving $30,000 to build the S.C. Lunatic Asylum and school for the deaf and dumb. This legislation made South Carolina the second state in the nation (after Virginia) to provide funds for the care and treatment of people with mental illnesses.
Robert Mills, a renowned architect, was chosen to design the new S.C. Lunatic Asylum. In 1822 the cornerstone was laid for the Mills Building, which took six years to complete. The building's many innovations included fire-proof ceilings, a central heating system, and one of the country's first roof gardens. South Carolina's asylum was one of the first in the nation built expressly for the mentally ill and funded by a state government.
Citizens were wary of sending their loved ones to the asylum, and so, it was not until December 12, 1828, that the first patient was admitted. A young woman from Barnwell County, she was accompanied by her mother who worked as a matron while her daughter was a patient at the hospital.
The hospital admitted patients wealthy enough to pay for their own care, as well as the middle class and paupers. Although a few blacks, mostly slaves, were admitted during the first 20 years, they were not officially permitted until 1848.
Despite its innovative architecture, many problems arose within a few years after the asylum opened. Complaints ranged from narrow halls and staircases and small activity rooms to flooding on the ground floor. Another issue was expansion of the asylum grounds.
By the 1850s, the average patient paid $250 annually. A separate room and eating area cost another $100. Paupers were admitted for an annual fee of $135, which was billed to the patient's home district. As more paupers were admitted, it became harder to collect fees, and the asylum grew more dependent on state funding. Due to the large number of people being admitted land was needed for new buildings and for patient recreation and gardens. Some asylum leaders believed the institution should be moved to the country. Largely because the legislature was unwilling to fund a new complex, it remained at the original location. Land was purchased next to the complex, and more buildings were erected. The headquarters for the South Carolina Department of Mental Health remain on these grounds even today.
Men and women were housed separately, originally on different floors, but later in separate buildings. When a new building was completed in 1858, male patients moved into it, and the women remained in the Mills Building. Despite the new building, the asylum reached its capacity of 192 by 1860. Many families preferred to care for their mentally ill relatives at home, while others wanted them closer to home even if it were in the county jail or the poor house. Only after the state assumed direct responsibility for all mentally ill in 1871 did county jails readily give up their patients.
During the Civil War, funding problems grew worse. Dr. John W. Parker, the superintendent, opposed a plan to turn his complex into a prisoner-of-war camp. Although the Confederate Army did not get the asylum, the grounds were used as a prison camp for Union officers from October 1864 to February 1865.
Despite worsening conditions late in the war, the asylum became a refuge for many Columbia residents when the city burned during Union General William T. Sherman's occupation in February 1865. With dwindling provisions, Parker did his best to provide for his patients and for the destitute citizens.
Like the rest of the South, the asylum struggled to survive in the aftermath of the war. Despite the lack of funds, the superintendent accepted more patients and often used his own money to provide them with food and other necessities.
J.F. Ensor, a Maryland native and former Union Army surgeon, became superintendent in 1870 and tried hard to find adequate funds for the institution. Several citizens from around the state contributed, and he received a $10,000 subscription from some Philadelphia Quakers, which helped repair the buildings. More than once, when local businesses could no longer give him credit, Ensor supplemented the institution's meager budgets with his own funds.
As the population grew, it became virtually impossible to treat patients. The asylum became largely a dormitory to house the mentally ill.
In 1870 Ensor reported that the rundown asylum rooms "were mere cells of chink in the wall, dark and illy ventilated" and that there was not an adequate means of diagnosing patients. These problems were solved to the best of his ability. By 1874 Ensor had added central heating, plumbing, new furniture, pianos and books.
While Ensor made some strides in providing for patient's physical needs, overcrowding remained a problem. This accelerated when the state government assumed the cost of patient care from the counties in 1871.
With slavery abolished, African-Americans became a larger part of the asylum's population. The admission of blacks not only added to the patient population, but led to another problem-providing separate facilities for the races. Temporary structures built before 1860 for blacks desperately needed replacement. Facilities for whites also were overcrowded.
While trying to accommodate this population increase, Ensor was forced to cut staff to have funds to buy food and meet other needs. Sometimes this was not enough. Even though the state was now required to pay for patient care, some asylum residents were sent home if they had no money to pay for their care. Nevertheless, the population increased from 245 in 1870 to more than 300 by the time Ensor resigned seven years later.
Notable changes before 1900 included the founding in 1892 of a nursing school, which did not close until 1950, and changing the hospital's name in 1896 to the S.C. State Hospital for the Insane.
Although hospital finances became more stable in the 1880s, the legislature instructed the superintendent to economize wherever he could. While most states were increasing their annual per capita spending, South Carolina was reducing hers. The cost for each patient in 1877 had been $202. It was reduced to $140 by 1888. Nine years later, the per capita rate had fallen to $107.80, one of the lowest in the nation.
By 1900 the State Hospital had 1,040 patients. More than 30 percent of them died annually, due in part to poor living conditions and inadequate supervision. More facilities were built in the 1870s and 1880s, including two major additions to the buildings constructed in the 1850s northeast of the original Mills Building. However, the population outgrew these by 1900.
By 1910, after a legislative committee reported the asylum was too small, land was purchased north of Columbia, and plans were submitted for a new complex that became known as "State Park." When it opened in 1913, it was for black patients only. This hospital, named Palmetto State Hospital in 1963, was renamed Crafts-Farrow State Hospital in 1965 when it became a geriatric facility.
A legislative study of the asylum in 1909 found many problems, ranging from poor sanitation and dilapidated buildings to situations in which patients lived in unclean quarters or were forced to sleep in corridors. Many of the problems at the state hospital were common to facilities nationwide.
Dr. C. Fred Williams, superintendent of the S.C. State Hospital from 1915 to 1945, realized the need for community mental health clinics. He encouraged a program to educate the public about mental illness, its causes and methods of prevention.
The first clinic to provide services for the mentally ill who did not need hospitalization was opened at S.C. State Hospital in 1920. The first permanent outpatient clinic opened in Columbia in 1923. The success of this clinic inspired the opening of traveling clinics in Greenville and Spartanburg in 1924.
By 1927 clinics were established in Florence, Orangeburg, and Anderson. In 1928 a clinic opened in Charleston with plans for one in Rock Hill.
World War II came, and doctors, nurses, and social workers went war. The State Hospital staff was depleted, the clinics began to suffer. In early 1943, the Orangeburg and Rock Hill clinics closed for the duration, and on Nov. 1, 1943, Dr. Williams informed all of the clinics that they would be closed for the remainder of the war.
Reopening of the clinics was delayed until late 1947 because of a lack of adequately trained personnel. As clinics continued to grow over the state, the need for state and federal funding increased. Help came in 1946 with the passage of Public Law 487 and in 1952 with the passage the Mental Health Act.
Public Law 487 provided federal funds from the Surgeon General, U.S. Public Health Service, for adequate mental hygiene clinics. The Mental Health Act provided for a Mental Health Commission to be in charge of all mental health facilities. Communities were required to contribute one third of the cost of clinic or center operation and the state would furnish the remaining two thirds.
In the mid - 1950s, the discovery of phenothiazines, "miracle drugs" that controlled many severe symptoms of mental illness, made it possible to "unlock" wards.
By 1957 clinics were in operation in Charleston, Greenville, Richland, Spartanburg, Darlington, and Florence counties.
Major functions of theses clinics included: cooperation and consultation with other agencies and professional people in the community; evaluation and treatment of emotional disturbances in adults and children; public education; and training psychiatric and pediatric resident doctors from the Medical College Hospital.
In addition to self-referrals, patient referrals to the centers came from physicians, ministers, lawyers, vocational rehabilitation, juvenile and domestic relations courts, and the Department of Public Welfare.
Two national events in the 1960s helped spur a large-scale relocation of patients with chronic mental illness to communities in South Carolina. First, the introduction of Medicaid and other improvements in the social welfare system underwrote the treatment of patients in their own communities. In 1963, the Federal Community Mental Health Centers Act provided matching federal funds for constructing community mental health centers.
In 1964, the S.C. Department of Mental Health was created as an independent agency of state government to develop a more comprehensive system, which combined medical care and treatment with expanded community services, mental health education, consultation, professional training, and research.
William S. Hall, M.D., became the first State Commissioner of Mental Health in South Carolina. Under Dr. Hall's enlightened guidance from 1964 to 1985, the agency made significant advances in community care. A comprehensive, statewide mental health care delivery system emerged and grew to encompass 10 major inpatient facilities and 17 community mental health centers providing services in all of the state's 46 counties with more than 6,000 employees.
During the 1970s, South Carolina experienced a number of firsts. They included the establishment of a transitional living project to help patients return to the community after long hospital stays, a facility for psychiatric patients who need long-term care, a program for autistic children, and an alcohol and drug addiction treatment center.
Patient's rights became an issue in the 1970s. The department embraced the movement by creating the position of ombudsman and a system of advocates to protect the rights and privileges of the patients and to serve as an intermediary between patients and the department.
By the end of the 1970s, the time had come for a renewed emphasis on the care of the chronically mentally ill. A report by The President's Commission of Mental Health in 1978 jump-started the effort. The commission, headed by then-First Lady Rosalyn Carter, for the first time put the care of people with serious mental illnesses on the front burner of federal concerns.
Although the 1980s began with great promise for people with mental illnesses, those hopes were short-lived. The 1980 Mental Health Systems Act, which promised new resources and refocused federal support of the care of persons with severe mental illnesses, was effectively repealed by the Omnibus Budget Reconciliation Act of 1981. The result-federal resources, available as block grants, shrank dramatically.
In 1983 the S.C. Department of Mental Health adopted a plan calling for the development of community-based services, the decentralization of hospital services, and a significant decrease in the population of its psychiatric facilities in Columbia. Funds were made available through an emergency stabilization plan to any locale that could develop programs to reduce admissions to the central facilities.
Fiscal restraints led to frustrations on the state level, particularly in funding proper care for patients in the state hospitals. In 1985 a U.S. Justice Department's critique of the S.C. State Hospital said conditions there were "flagrantly unconstitutional." The Justice Department entered into a four-year consent decree with the state of South Carolina in 1986 to provide increased services for all patients.
Joseph J. Bevilacqua, Ph.D., became the state commissioner of mental health in 1985. Under his leadership, the department supported the view that patients treated in the community do much better clinically. People with mental illnesses need and require close family and community support. They get better faster and stay better longer when they receive services in their community, if such programs are reasonably funded, well organized and easily available.
In February 1989 the S.C. Department of Mental Health, with support from the National Institute of Mental Health, hosted a national conference entitled "The Role of the Public Mental Hospital in a Community-Based System of Care." The purpose was to explore how other states shifted to community-based services, how they defined priority populations, and how they planned and located services.
An outcome of this conference was the initiation of the Transition Leadership Council. An unprecedented collaboration between mental health professionals, government, mental health advocates, and consumer representatives, was formed to spearhead the movement of South Carolina's mental health delivery system Towards Local Care.
The council determined that the services necessary for the successful transition of patients into the state's communities did not exist and needed to be developed. It was also clear that some patients could not be safely discharged into the community and would continue to be cared for in S.C. Department of Mental Health facilities until appropriate services could be created.
Some communities are struggling to develop community-care programs. They have a shortage of appropriate residences and sometimes face opposition to these from neighborhood residents, have no crisis-care center to handle short-term acute situations, lack employment opportunities, and, particularly in rural areas, lack good basic medical services.
However, many areas are successfully developing mental health services. An example of the success of the program occurred between May and November 1993 when 127 patients from the S.C. State Hospital and Crafts-Farrow State Hospital moved into seven creative, customized programs in Aiken, Charleston, Columbia, Lexington, Orangeburg, and Sumter. These patients were provided with appropriate residences, medication monitoring, psychiatric and medical services, supportive community services, meaningful activity, and employment assistance.
In two separate waves of programs from 1992 to 1995, 265 patients were discharged from inpatient facilities to Toward Local Care projects that have a total budget of $4 million.
In the first Toward Local Care wave, 193 clients entered the community from hospitals to nine community mental health center programs.
In a second wave, 44 clients were discharged to programs in six community mental health centers (Anderson, Charleston/ Dorchester, Columbia, Greenville, Pee Dee and Piedmont).
Moving more people with mental illness to community treatment has meant reducing the population of the psychiatric hospitals in Columbia. In 1996 the S.C. State Hospital and Crafts-Farrow State Hospital consolidated their services and moved patients from Crafts-Farrow State Hospital to the S.C. State Hospital campus. This consolidation resulted in the organization of the Division of Psychiatric Rehabilitation Services comprised of 410 beds. Today entire floors, wards, and cottages on the Columbia campus are closed or are used for administrative offices.
In 1995 the S.C. Department of Mental Health served 90,492 clients in its 17 community mental health centers and 13,422 in its five psychiatric hospitals.
This brief account of the S.C. Department of Mental Health's illustrious history has only skimmed the surface of a deep and abiding commitment to provide quality services to people with mental illnesses.
Others have expressed our commitment and direction more eloquently.
At a banquet on the occasion of the laying of the Mills Building cornerstone, Col. Levy, vice president of the Lunatic Asylum, offered a toast setting the direction for the state's concern about mental health care, saying, "The Lunatic Asylum-may it long flourish as an asylum for the afflicted and a monument of the humanity and munificence of the people of South Carolina."
Dr. William S. Hall made the following statements during the 150th anniversary of the S.C. Department of Mental Health, "From a plateau of better understanding and broader knowledge we can look back on early treatment programs with chagrin, but we must remember that, in many cases, such was the extent of knowledge in those times. We honor those men of integrity who first gave us guidance and directions. From them we have accepted the torch of responsibility. I wonder how history will treat us 150 years from now? I hope we will be treated as kindly, with as much compassion, as we view those who preceded us."
In summary, John A. Morris, interim director, said in 1996, "As mandated in our agency's mission statement, we have formed partnerships with consumers, families and other diverse communities to make sure that all clients who need our services receive them, that they receive state-of-the-art services, and that we provide services in the most efficient and effective manner possible. As you see from this brief history of our agency, there's nothing new to the Department of Mental Health about those concepts. It is our hope that the next century will see continued development of local mental health care and that greater acceptance will allow people with mental illnesses to live with dignity in communities of their choosing."
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*This information was provided by the May 1996 issue of the South Carolina Department of Mental Health's FOCUS publication and Changing Minds, Opening Doors: A South Carolina Perspective on Mental Health Care. Both of which were written by Susan Craft for the South Carolina Department of Mental Health.