PennForest

In the late 19th century, state governments in the US (along with other countries around the world) started to fund large facilities to house and treat children and adults with “mental disabilities”.  If a person was declared mentally disabled, they were designated as a threat to the public welfare and they lost their legal rights. As overcrowding inevitably occurred in these facilities, patient management became more restrictive. Patients that misbehaved were controlled or punished with restraints, isolation, removal of teeth (for patients that bit other patients), and withholding of food or medicine. 

This story, though fictional, is based on this part of our history. 

Pennforest

One

Dr. George Walsh’s train pulled up to the station on Main Street in Royersford, Pennsylvania. Walsh stepped onto the train platform and looked around. He was a tall man with white hair and an auburn mustache. He was dressed in a dark grey, three-piece suit with a light grey Jeff Cap. It was a quick walk up Main Street to hail a cab in front of the Royersford Hotel. The street was bustling with cars and trolleys moving up and down the graded road. 

Walsh had traveled from Boston, where he had established himself as a prominent figure in the burgeoning psychoanalytic community. Originally a psychiatric hospitalist, he became one of the first professors for the Greater Boston Psychoanalytic Institute – a training program for medical doctors in Sigmund Freud’s groundbreaking psychotherapeutic approach. Walsh quickly rose to notoriety in the Institute, with his knack for applying psychoanalytic theory to various bizarre patient presentations. However, his focus on establishing a close relationship with patients ran counter to the “pure technique”, the required emotional distance fundamental to the psychoanalytic approach. After a number of censures from the faculty, Walsh was eventually encouraged to leave the training program after 15 years.

Walsh asked the bellhop in front of the hotel to hail a cab.

“Where’s that accent from? New York?,” asked the bellhop.

“No. It’s from Boston,” Walsh said with a smile on his face.

“Do you have a meeting in town?”

“I’m actually starting as Medical Director of the Pennforest Hospital tomorrow.”

“Oh. My sister works at the hospital as a nurse. Her name is Marcie. Sounds like an interesting place. A lot of stories about those buildings.”

“Yea?,” said Walsh. “What kinds of stories?”

“You know. Usual stuff with a mental asylum. You hear about patients that died and still walk the halls. Stories about the doctors doing experiments on the patients. Patients violent toward the staff. That sort of thing. I’m not sure about all that. But I suppose it’s a bunch of weirdos in there.”

A short taxi ride took Walsh across the Schuylkill River. They took a narrow road into a patch of woods and to the entrance gates of the Pennforest State School and Hospital. Walsh arrived in front of the Administration Building, a grand stone building with an ornate bell tower on top. As Walsh stepped out of the taxi, he noticed it was quiet on the grounds. The forest insulated the area from the sounds of the nearby town.

A middle-aged nurse walked from the Administration Building to greet Walsh. She wore a long white nurses dress with a fitted hat on her head. She extended her hand and said:

“Welcome, Dr. Walsh. I’m Marcy Dench. We’ve spoken over the phone a few times. I’m head of nursing and I’ll show you around today and get you settled into the director’s house.”

“Thank you, Mrs. Dench,” said Walsh.

“Oh. It’s Ms. Dench. But you can call me Marcy.”

“My apologies. Ms. Dench. I look forward to seeing the grounds.”

Walsh hadn’t traveled to Pennsylvania when he interviewed for the job. He met with a state official that was traveling through Boston and spoke with people over the phone. So the tour with Marcy was his first look at the grounds. 

He and Dench first went into the Administrative Building to fill out Walsh’s paperwork for payroll and change of residence. Walsh noted:

“There isn’t a lot of staff on the weekend.”

“No,” said Dench. “Two-hundred employees will storm the grounds on Monday morning. But the weekend is quieter around here.” She continued, “Let’s go to the hospital building first.”

Two

The Pennforest State School and Hospital was a sprawling 650 acre compound. It was its own city, with a railroad stop for supplies and a dedicated power plant. In total, there were over 30 buildings on the property. The institution was originally intended to hold around 500 patients. At Walsh’s arrival, its resident census was approaching 1000.

Nurse Dench showed Walsh the three-story hospital on the outside edge of the grounds. The concrete building was very plain; the design was utilitarian instead of warm and welcoming. 

On the first floor, there were primary care wards for the residents as well as a ward with x-ray and surgery. There was also a ward for dental work. Beyond traditional medical treatments, the psychiatric treatment ward on the second floor used cold-water baths, electroconvulsive shock therapy, insulin therapy, anti-convulsive therapies, and sedative medications for children suffering with more severe psychoses or mood instability. Walsh and Dench walked past children lying, half-conscious or unconscious, on beds.

Finally, Dench showed Walsh the largest area of the hospital on the third and fourth floors; rooms filled with beds that looked like large cribs. The space was cramped. Walsh and Dench walked down hallways lined with beds, which led into small rooms filled with beds, which led into another hallway lined with them. There were only a few staff members on each floor. The air on this floor of the hospital was stale, with a scent of body odor or feces. There was very little moving air and it was overly warm.

Many children were sitting up on their beds rocking. Some residents were lying with soft restraints (such as strips of cotton linen) tied to their wrists and ankles.

“These areas didn’t exist until a couple years ago,” said Dench. “When the campus became overcrowded, we had to start separating the residents with severe disabilities. If someone couldn’t live with the rest of the population, they were assigned to these beds in the hospital.”

Walsh became very quiet in this space. “How long do they stay like this?”

“The staff rotates from resident to resident every 15 minutes. We try to take them to the bathroom and let them walk around for a bit. A lot of them wear diapers.”

“They’re children,” Walsh said under his breath. “How many patients are currently on this floor?”

“Sixty-seven,” said Dench. 

Walsh started doing the math out loud. “Four an hour……sixty-seven divided by four. That’s seventeen hours to take the kids to the bathroom. They get up once a day. Do they sleep here?”

“Yes. It’s the only way we can care for them,” said Dench. 

“Who came up with this plan?,” asked Walsh, his voice much louder. 

“Someone from Harrisburg. We hear they do this at all the state hospitals,” said Dench. 

After visiting the “severe floors”, Walsh and Dench left the hospital and toured one of the boy’s residential buildings. These brick buildings were built in a cottage style, making them look more like a big house rather than a dormitory. However, as Walsh walked down a hallway on the second floor, it felt like patients were cramped inside these rooms, too. Walsh was reminded of the military barracks during his medical service in the Army. The residential buildings had the smell of a harsh, citrus cleaning agent. 

Dench and Walsh stopped to say hi to a patient that was sitting in a wheelchair in the hallway near the entrance of his room. In the room, two other residents were laying on their beds.

“Hey Roger,” Dench said to the teenage boy at the door.

“Hi, Nurse Mary!,” the boy said a little louder than needed. Dench didn’t mind the wrong name.

“What are you boys doing?,” asked Dench.

“Don’t know. Lunch is at noon.”

“This is the new medical director. Dr. Walsh.”

“Hi doctor! I can’t walk because I had polio,” said Roger.

“Is that right, Roger?,” said Walsh. “I’m looking forward to spending more time together.”

As Dench and Walsh left the residence, Walsh asked:

“Where are the patient files?”

“The current files are behind the nursing stations in the hospital,” said Dench.

“How far back do the current files go? How many years?,” asked Walsh.

“Um, most files probably cover the last three years. Some may go back as far as five years,” said Dench.

“Where do you put the files that are older than that?,” asked Walsh.

“There’s a records closet in the basement of the hospital. I can get the key from administration if you need to get in there.”

“Yes. Thank you,” said Walsh. “After getting settled into my residence, I’d like to review files for the rest of the weekend. I need to get up to speed before our staff meeting on Monday morning.”

“Sure,” said Dench. “I’ll introduce you to the rest of the nurses and get you set up with what you need.”

Three

Walsh settled into the director’s house, a colonial style house with four bedrooms, big windows, and a large front porch. It sat in a large, mowed field. Walsh didn’t know what he was supposed to do with all the space. His wife had passed three years prior and their kids were grown adults.

Through the rest of the afternoon and the next day, Walsh looked through current and past patient files at the nurses stand and in the damp basement of the hospital. He created a stack of files to take to his house, and for the rest of the weekend read in front of his fireplace.

During one of his file reviews, Walsh returned to a memory of his late wife washing the dishes in the kitchen in their house in Boston:

“I talked to Rob today. He and Jill are bringing the boys for Thanksgiving,” said Michelle.

Walsh snapped his finger in excitement. “Maybe I’ll get Rob to bring the boys hunting on Thursday morning.”

“They’re too young for that, George,” Michelle said with a bemused smile on her face. 

Walsh warmly placed his hands on Michelle’s shoulders from behind. He gave them a squeeze. 

“They’ll just watch. They’re the perfect age to learn.”

Michelle turned and put her arms around Walsh’s waist. 

“You want those boys to be little copies of you. Just like Rob,” Michelle said softly.

“I just want those boys to live life fully. They have so much to experience.”

Walsh kissed his wife on the forehead.

On Monday morning, Walsh had scheduled a meeting for the entire Pennforest clinical staff. It was rare for the whole staff to be in one place due to the need for constant patient or resident care. In fact, some of the night shift staff were covering the nurse station and residence desk to allow the full-time clinical staff to be present. 

The clinical staff was gathered around a very long table in one of the dining halls. The room had the smell of cooked potatoes. Walsh sat down at the head of the table.

“Good morning,” he said in a soft voice.

“Sir, we can’t hear you down here,” said one of the nurses’ assistants.

“Sorry. Good morning. I’m very excited to be here. Being your director is a privilege at such an important institution. I wish we had more time to get to know each other, but we’re going to dive right in today. I want to spend the next hour hearing from you about the treatment and residential process here at Pennforest. So, lets start here. The residents are classified under two criteria: ‘insane’ versus ‘imbecilic’ and ‘epileptic’ versus ‘healthy’.” The words felt strange coming out of Walsh’s mouth. He continued:

“They are also evaluated based on dental condition, but this doesn’t seem to determine residential status. I can see a little bit from the patient charts how the basic criteria are decided. But there is no documentation of the evaluation process. Can someone more clearly define the evaluation of these categories and how they are decided?”

Most people at the table looked around at each other with an expression of confusion. It occurred to Walsh that the staff weren’t used to participating in decisions/discussions of administrative matters. After a long silence (with Walsh just sitting patiently at the head of the table), Marcy Dench raised her hand.

“Yes. Ms. Dench.”

“A few of our nurses are assigned to the initial evaluation when a resident arrives. We use whatever information we can to make the classification. Frankly, the most important decision is which resident population the individual fits into. If they’re verbal and stable, they’re placed in the regular residence halls. If they’re non-verbal, emotionally labile, psychotic, or physically disabled, they’re assigned based on their needed level of supervision.”

“Ok. So the initial decision is based on their residential status. How are treatment decisions determined?,” asked Walsh.

Dench continued, “We’re better able to assess their medical needs as they get adjusted to living with us. There is a medical evaluation, like a physical, at the hospital after residents are settled into their residential placement. As we get a better sense of their functioning, we can assign them to their school levels or occupational task and their treatment plan.”

“The 2 by 2 by 2 assessment process means there are 8 possible categories – like ‘insane, epileptic, poor dental’, ‘insane, epileptic, good dental’, etc. Do these categories actually determine treatment? Are there other categories that you create as you get to know the patient?,” asked Walsh.

“Well, some residents have muscular problems,” said Dench. “We try to get them through various physical challenges, like building their arm strength and helping their mobility from their wheelchair to other seating areas.”

“Ok. So this confirms my suspicion,” said Walsh. “There are numerous categories that are not recorded for residents.”

A nurse toward the other end of the table raised her hand.

“Yes, young lady?,” responded Walsh.

“Hi, um, I wanted to ask, what’s the problem if we don’t record the categories? It’s just extra paperwork, right?,” said the young nurse.

“There are a number of reasons it matters, young lady. The hospital reports to the public x number of insane and x number of imbeciles at our hospital. For the public and lawmakers, the residents are seen in these simple ways. If we’re going to get the resources we need and educate the public, we need to be using the right language. Also, we need to communicate clearly with each other. Have people heard of muscular dystrophy?”

The staff looked around at each other. A thin man with a white coat, one of the psychiatrists on staff, spoke for the first time:

“Yes. We know what muscular dystrophy is.”

Many staff still had a confused look.

“Ok. Good!,” said Walsh. “We can start using that category when residents present with it. Over the next two weeks, I have a task for the entire staff. I want you to write down whatever label or name you would use to describe one of the common issues among the residents. Use an extra piece of paper and put them in my mailbox. Any questions?”

The staff sat in silence again. Walsh rose and extended his arm to let the staff know they could adjourn.

As Walsh walked out of the dining hall, the thin psychiatrist approached him.

“Hey. I’m George Walsh,” said Walsh, extending his hand to the psychiatrist.

“Dr. Abe Burns,” said the psychiatrist, shaking his hand limply. Burns was a notably shorter man with thin features and sunken eyes. He barely filled his clothes. 

“You keep talking about treatment. You know what this place is, right?,” asked Burns.

“Yes. Generally,” said Walsh with a smile. “But I’m curious to hear more from the people that have been here.”

“Well, let me give you your first lesson about this place. These people are seen as rejects. Their parents drop them off at the door and keep going. It’s a pity. We have our hands full keeping them alive. The staff has enough burden as it is. They don’t need more tasks.”

“Ok.” Walsh paused for a second. He wanted to stay non-defensive. “Thanks for your input. I don’t know this staff yet, so I’m not sure how much they can handle. Good to meet you, Dr. Burns.”

Five

By the next day, Walsh was already receiving new categories in his mailbox. He was delighted to see that the staff were responsive to the task.

Later in his first week, Walsh traveled to the state capital, Harrisburg, to meet with the Governor and the Pennsylvania Commissioner of Health. 

Governor Charles Hiester was in the third year of his first term. He was best known for his budget cuts across the board in the PA legislature. Expenses and inflation had boomed in the 1940s. The recovery from the Great Depression and the influx of industry to the state during World War II left the state in a position to actually balance their budget. It was a popular line for Hiester politically to say he’d balance the budget by the end of his first term. The public didn’t realize this meant public programs (like the state hospital system) were gutted.

Walsh walked into the palatial capitol building in Harrisburg. He walked up the grand staircase in the middle of the capitol to the third floor. An assistant greeted him outside the governor’s office and asked him to take a seat. 

After a twenty minute wait, Heister walked out to greet Walsh. Hiester was a tall, large man. Walsh’s first thought was he could have played offensive tackle for the Big Ten. Hiester’s three-piece suit was slightly rumpled. 

“Dr. Walsh! Thanks so much for coming,” said Hiester. “Right in here.”

The governor led him into a spacious office with ornate wood paneling throughout the room. The Commissioner of Health was seated behind a meeting table. 

“This is Rex Fillmore, the Commissioner of Health,” said Hiester.

Walsh reached out and shook the commissioner’s hand as Fillmore stood.

Hiester flopped into a chair at the head of the table. “Well, this is sort of a meet-and-greet, George. Rex has some graphs and numbers to show you, but this is generally a chance for us to get to know each other. We were thrilled with your hire at the hospital.”

“Thank you, sir,” said Walsh. 

“How are you settling in?,” asked the governor. 

“Quite well. Thank you, sir.”

“Good!,” Hiester’s booming response came before Walsh could even finish speaking. “Obviously, these hospitals are very important to the state. The staff do honest-to-goodness good work with the retarded kids in these places,” said the governor.  

“Yes, sir.” His stomach dropped at the word ‘retarded’.

“Now, Rex. Why don’t you show George some of our projected numbers?”

Fillmore sat up and opened a thick portfolio. The first pages had brightly colored, detailed graphs. Fillmore stated in a presentational tone:

“If you look at our budget in the first half of the 20th century, our hospital costs have ballooned wildly. From 1940 to 1945, expenses went from $153,000 to $425,000. More than doubled in 5 years. At this rate, the hospital system will be 25% of the whole state budget by 1980. So, a new fiscal model is imperative.” He stated the last sentence by jabbing the graphs with his pointer finger with almost every word. 

“So, this is one of our goals, George,” said Hiester. “We need to start managing these hospitals more efficiently. We’re proposing a moratorium on spending increases for the next 3 years and a reduction by 15% in the next ten. Anyway, like we said, this is just some introductory information. For now, we want you to get settled in.”

“Sir, I took my first tour of the facility on Saturday. It’s dramatically overcrowded. Are we planning on a stop to new patient admissions as well?”

“You don’t need to worry about that now, George. Rex’s assistants will be in contact over the next couple months to talk details. I just wanted you to get a sense of the overall strategy,” said Hiester.

“But, sir, respectfully, the hospital needs immediate changes now. That’s what I wanted to share during this meeting. If we have more patients coming in, we’ll need more money for housing and patient care just to keep up,” said Walsh.

The governor and commissioner made eye contact. Hiester responded with a calm, quiet tone:

“George. We don’t even know each other yet. Remember, you’re talking to the highest ranking official in the state. You’re brand new.” The governor turned his dour expression into a smile. “This is a great job! You’ve done well for yourself to go from a disgraced psychiatrist in Boston to the Director of a state hospital right outside Philadelphia. The birthplace of our nation. Take your time and get acclimated. Enjoy the accommodations.”

Walsh nodded hesitantly. He knew he wasn’t going to be allowed another word.

“Thank you for coming in, George,” said the governor. 

“Thank you for having me, sir,” said Walsh. “Good to meet you, commissioner.”

The governor waved Walsh toward the door. 

Six

On the train ride east back from Harrisburg, Walsh kept thinking about his last meeting, two years prior, as a faculty member of the Greater Boston Psychoanalytic Institute.

A man in a black suit sat at the head of a long boardroom table. Rain tapped against the large windows lining the room.

“Ok. Lets get started,” said the director.

A few men in shirts and ties took their seats after visiting the coffee and danish table. The director waited a few seconds until the room quieted. 

“Ok. We’ll open up the board meeting for the Greater Boston Psychoanalytic Institute. All twelve board members are present today. Our secretary will be keeping the minutes of the meeting. We will open up to agenda items in a few minutes, but we start our meeting today with another censure meeting for Institute faculty member Dr. George Walsh. Dr. Walsh has been censured twice previously for violations of the teaching and practice standards at the Institute. This most recent censure arose from a disagreement in the faculty meeting held on September 8th of last year. The faculty chair submitted a complaint to the board following the incident, citing ‘misconduct in a faculty meeting’ and ‘gross violation of the teaching and practice standards of the institute’. 

“Dr. Walsh, do you wish to have representation present for this censure?”

Walsh sat in his chair, staring down at his notepad. “No. Thank you,” he responded.

“Do you have a response to the censure, Dr. Walsh?”, asked the director. 

“Yes,” said Walsh. He read from an index card on the table. “I’d like to end my time at the Institute with this brief request: that current and future faculty and students look past the technique of psychotherapy and focus on the intensive, living experience of the helping process. The treatment comes from a human encounter, not a set of experimental techniques.” 

“Ok. Thank you, Dr. Walsh. The Institute board and faculty, including Dr. Walsh, have been informed prior to this meeting that Dr. Walsh’s position in the Institute is terminated without possibility of return to the Institute. This termination is effective immediately. We’ll ask Dr. Walsh to leave the meeting at this time.” 

———————————

Walsh didn’t sleep that night. He laid in bed staring at the ceiling much of the night, followed by pacing the kitchen with a cup of tea until morning. He had the weekend to continue to construct a housing and treatment policy for the hospital. He had been hoping to go through the budget, line-by-line and request an increased budget for significant changes at the institution. But, now, he had to propose changes without any new money. He could still scour the budget and move money around, but it wouldn’t cover the housing and staffing he’d need to overhaul housing and treatment. 

The next morning, Saturday, he called the front desk of the administrative building. He asked the assistant to call the senior staff of the hospital: Marcy Dench, head of nursing; Abe Burns, head of psychiatry; Ronald Brown, head of medicine; Peter Eldridge, head of dentistry; Alport Myers, head of facilities; James Job, head custodian; and Marshall Wexler, head of dining. 

“What should I tell them they’re being called in for?,” asked the assistant.

“Our new plan. Thank you!,” said Walsh.

At noon, Dench, Eldridge, Myers, and Job sat around a smaller, round table in the cafeteria dining room. Walsh wheeled a chalkboard into the room and sat in one of the four remaining seats. 

“Wexler can’t join us,” said Walsh. “He’s working in the back. Anyone know where Burns and Brown are? Anyone hear from them?”

The other four shook their heads.

“Ok. This group, including Wexler, will make policy decisions for now. If the others want to be involved, ask them to come speak to me.

“Let me ask you,” said Walsh in a soft tone. “Why do you think these kids live here? Why are they sent to an asylum?”

There was an extended pause. Marcy was the only member of the group without a pondering look. 

Job looked around and said, “Half of us aren’t doctors. Are we supposed to answer?”

“You’ve been around these patients most days of the week. You must have an idea why they’re here,” said Walsh.

After another pause, “Well, I assume it’s because they’re disabled. Right?,” said Job.

“But there are people with disabilities that are taken care of at home by their family,” said Walsh. “What’s different about this group?”

“It’s mostly mental disabilities,” said Eldridge. 

“Yes. And what else. At a more fundamental level?,” asked Walsh.

The group looked around at each other, all except Dench. 

“Marcy?,” said Walsh. “What’s different about this group?”

“They scare people,” she said.

“That’s right,” said Walsh. “Anyone that is put in charge of these children eventually becomes scared or overwhelmed. Because they don’t understand how to get through to them. Or, in some cases, they don’t even want to try.”

Walsh waited a few beats for that to sink in. “We’re going to understand them. We’re going to connect with them. However long it takes. And we’re not going to be scared of them.”

Eldridge, Myers and Job were nodding but they didn’t appear to know why. Dench looked at Walsh with a small smile.

“We’re going to take a new approach to residence and treatment, and we have no extra money to do it,” said Walsh. “ We’re going to have to be creative and we’re going to have to tolerate change. Any questions so far?”

“Are buildings ‘Y’ and ‘Z’ still on schedule to break ground next year?,” asked Myers.

“I don’t know. But I wouldn’t count on it,” said Walsh.

“Other questions?” Walsh waited a few beats. “Ok. Our top priorities are housing and treatment planning for the severe ward. No more cribs. Second, we need to establish more housing for the general population.”

Walsh stood and wrote “Severe ward” on one side of the chalkboard and “General Housing” on the other. Under “General Housing” he wrote “Director’s House: 4 rooms, 8 occupants”.

“The director’s house is huge. I only need my room on the main level and the rest of the house can be shared space. I have no need for the other 4 bedrooms, so we’ll move two patients into each room. 

“We have large fields all over the property. How would we organize large field tents?”

With a perplexed look on his face, Myers said: “Wait. Field tents?”

“Yes. Or something like it,” said Walsh.

Job waved his hand and said, “We could talk to the Pennsylvania National Guard. Ask if they have field tents that are outdated or unused. They might even set it up for us.”

“Beautiful!,” responded Walsh. “Can you call them?”

“Uh, okay,” said Job.

“We need to use the largest rooms in the cottages for the severe population,” said Walsh. “They need space for special arrangements, like medical equipment. And we can design the rooms to be softer, so they’re quieter and lower stimulation.”

There was silence while Walsh wrote on the board. Eventually, Eldridge raised his hand.

“What do you mean by low stimulation?,” he asked.

“I’ve been reading about children with intellectual disabilities and autistics,” said Walsh. “The first thing I notice when I go into the severe ward is the number of children rocking back and forth. Have you ever wondered why that is?” Walsh didn’t seem to be asking anyone in particular.

“I’ve always thought they were out of it. In their own head,” said Job.

“Actually, I think they’re hyper-aware of what’s going on around them. I think the rocking is a way of soothing themselves,” said Walsh. “Can you imagine the agony of being in a wide-open room with dozens of people with hyper-awareness of loud sounds, brightness, and sometimes being tied down?”

“But we don’t have enough rooms for all the severe children,” said Myers.

“We’ll need to assess the highest needs. For the kids that are more stable, socialization could be an important task,” said Walsh. 

Eldridge put his hand back up. “There’re bigger problems here. How are state officials going to feel about a city of field tents on one of their largest state facilities? What happens when there’s bad weather? How do you staff all these extra residential spaces? How do you staff individualized care for the severe population?”

“We don’t know yet, Peter,” said Walsh. “We’re going to work together and not worry about anyone outside this circle of people.”

Seven

The next two months was a flurry of activity across the Pennforest campus. The National Guard couldn’t involve itself in other state matters without orders from the governor, but the local Boy Scouts office sent a wave of volunteers to set up two full fields of large cabin tents. Each tent comfortably housed four residents. Most kids were excited to go “camping”. 

Though it was late spring and the weather would be safe for the next five months, the facilities crew would be installing steam radiators and insulation in each of the tents throughout the summer. An electrician would be working on creating a set of electric hookups for each tent by the middle of the summer, when fans were needed to address the hot, humid months. 

Under the new residential policy, patients without physical limitations and with milder intellectual or developmental disabilities were placed in the tents. Patients with physical limitations and milder mental disabilities were also able to more easily navigate the outdoor tents or first floor indoor residences. The rest of the indoor residential space was divided between patients with moderate physical or mental disabilities and the patients with severe disabilities. In Walsh’s residence, 8 older boys were assigned to the director’s house. Roger, who Walsh met during his tour, was one of the boys placed there. 

A rotation of nurses were assigned to direct care with the severe patients. Among the mild to moderate patients, the medical staff began to assign older, responsible patients to leadership roles. These student officers had the authority to instruct their younger peers and to notify medical or facilities staff when they needed assistance. Nurses and technicians rotated through these residential spaces to check in with the student leaders. A disciplined schedule of occupational work – for example, laundry, agriculture, horticulture, sewing, cooking, custodial -, school instruction, and physical recreation was instituted from sunrise to sunset. 

Walsh was able to offset the costs of these changes by moving money around in the budget as well as through some local fundraising. Unfortunately, though, Walsh had to lay off some cooking and custodial staff. The older children helped with these tasks.

Meanwhile, the medical staff instituted various new diagnostic categories and provided more physical and occupational therapy, medication management, and even psychotherapy with the severe and moderate population. 

One afternoon, after many of the changes had taken place, Marcy Dence had afternoon tea with George at the director’s house. This had become a weekend routine for them on Saturdays and Sundays. 

“I’ve never seen this place like this,” said Dench. 

“Like what?,” asked Walsh.

“So active while also being calm. So….I don’t know…..positive.”

“We’ll talk to the administrative team this week about next steps,” said Walsh. 

“Well, George, before next steps don’t you think we should see how the state reacts to everything. They haven’t signed off on this yet, have they?”

“Implicit consent, Ms. Dench. The state’s already demonstrated that.”

Dench was quiet for a moment. She hesitated, then finally said, “I don’t know George. I….Have you ever known authority to give away decisions. So far, it might just be the slow pace of government that explains the lack of response from the top.”

“You’re probably right, Marcy. But they can’t ignore the results, can they?”

“With all due respect, George, are you really that naive?”

Walsh gave a small chuckle. He rubbed his neck and looked into the dark pool of tea in his mug. 

“No, Marcy. I think I’ve gotten used to trying to keep everyone cheerful. It used to drive my wife crazy.”

“So,” said Dench. 

“So?,” asked Walsh. 

“How do we handle the state’s response?”

“We just wait, Marcy. Every day these kids have like this is a win.”

Eight

The following week, Walsh visited with the nursing staff while they worked with a group of kids with higher needs. These higher need kids were eating in the cafeteria for the first time since they arrived to Pennforest. The aim was to build basic motor skills eating with a fork and knife and to introduce some socialization. 

Marcy Dench was patiently showing one of the children how to hold their fork, when suddenly she startled the child when her scarf brushed the child’s ear. The child screamed and threw her arms, hitting Dench square on the forehead with her elbow. The cut was wide and clean; blood poured into Dench’s eye and down her neck. The rest of the children burst into screaming. It took the nurses hours to get them back to their rooms and to calm them. 

Shortly after the incident, Abe Burns attended to Dench’s wound. She would need stitches at the hospital after Burns cleaned the wound. Walsh stayed by Dench’s side since the incident. 

“When you push kids like this, they get hurt,” said Burns. “Or other people get hurt. Does this program help you feel good about yourself, Walsh? Do you come in, make yourself the hero, and then let the rest of us handle the fallout?”

Dench’s face was red. She looked ready to blow at Burns. Walsh allowed a few beats to pass.

“Abe, do you remember getting hurt as a kid? I remember moments like that,” said Walsh. “You know what happened next?”

He wasn’t looking at Burns directly and didn’t wait for an answer.

“I remember the grownups showing up. I felt better and I’d run back out to play.”

He turned to Burns, and right before leaving the room, “Their lives don’t always need to be careful and insulated just because they have developmental limitations. They need to take risks. They need to get bruises and scrapes. They need to learn.” 

At the door of the cafeteria, Walsh turned back to Burns, “Will you join me for tea at my house, Abe?”

Burns didn’t take his eyes off Dench’s forehead. “Make it something stronger and I’ll be over after my shift at 9 tonight.” 

Nine

Walsh was sitting by a small fire, reading the newspaper, when Burns arrived at the Director’s House. He knocked twice and let himself in. 

“Do you like gin, Abe?”, asked Walsh.

“It’s not my first choice, but that will be fine on ice,” said Burns. “It’s a little early in the year for a fire, isn’t it George?”

“You’ll learn when you get older, Abe, that you never really keep your bones warm.” Walsh smiled. “Do you want to sit by the fire or on the back porch?”

“It’s a nice night. Back porch.”

Walsh poured himself another cup of tea. He put two ice cubes in a small glass and poured a little gin. Then he walked into a screened porch on the back of the house where Burns was already seated. The crickets and cicadas continued their summer symphony, with about two months until the first freeze. Burns and Walsh sat in pillowed deck chairs.

“It really is beautiful tonight. A little cool for me but beautiful,” said Walsh. 

Burns looked at Walsh quizzically. It had been a warm day and hadn’t cooled much yet. 

“You care about these kids, Abe. I can hear it in your voice when you scold me about what I’m doing here,” said Walsh. “Tell me about your concern for them. What makes you care?”

Burns took in the smell of the gin and then took a slow sip.

“This job was my first out of residency. I’ve worked with these kids my entire career.”

“Is 8 years an entire career, Abe?,” Walsh said with a smile. 

Burns took another drink. His reaction to the gin was hard to parse. 

“Do you have kids, Abe?,” asked Walsh.

“No.”

“Married?”

“No.”

“Do you want to marry, have kids?”

“I rarely think about it. I’m probably getting too old.”

“What do you do when you’re not working?”

“Are we trying to be friends, George?”

“Maybe. But this is more like psychoanalysis.” Walsh smiled again. “Seriously, I’m trying to figure out whether we’re at odds or if we want the same thing.” 

“There’s something you should know, George,” said Burns. “I’ve been talking to the commissioner in Harrisburg for weeks. They’re going to fire you this week. The state is going to take over for a while.”

Walsh wasn’t entirely caught off guard, but it still stung. He figured this move was coming. He actually expected it earlier than this. 

“Do you really feel these changes haven’t helped these kids, Abe?”

“It’s a little better for now, but it’s a state facility. It’ll go back to the way it was and it’ll be even worse for the kids that had it this way.”

“When you would meet with the severe patients, tied to their cribs, how did you feel, Abe?”

“You can’t pity them. That’s the first thing. They can sense the littlest bit of pity. You have to respond to them calmly, dispassionately. In the end, the crib is more humane for these kids than what their parents would have done. What their eventual foster parents and foster siblings would have done. Than what they’d experience on the streets.”

“Abe, did you have a foster family?”

Burns stood suddenly and stared at Walsh. “You think you can just pry into people’s private business!” Burns held the stare for a few beats. “You should start packing,” he said as he turned to leave the house. 

Ten

It happened two days later. Walsh received a call from the commissioner, who told him he “was being re-assigned” at the end of the week. Harrisburg offered a position in a nursing home in Pittsburgh. Not as director or management, but as a service provider. His pay would be cut in half and he’d be on probation for six months. Walsh respectfully declined.

After saying goodbye to the staff, Walsh boarded a passenger train with his luggage for the second time that year. He was returning to Boston. He hadn’t yet secured a job, but he still had a farm outside the city that he’d take back from tenants. He was considering retirement. 

An unexpected development (or perhaps lack of development) occurred at Pennforest the next couple months. The state didn’t return the residences and treatments to status quo. In fact, Burns (the new “Acting Director”) was instructed to oversee an increase in field tents. Pennforest would become the flagstaff state facility, with more children sent to the facility than any other across the state. Budgets would still be cut across the state, but other facilities could be restructured to increase residential space at a low cost. It was eventually called the “Pennforest Model”. 

Dr. Abe Burns threatened to quit every week for a while, but eventually became the long-term director at Pennforest. He and Dench became good friends. Dench sent a letter to Walsh every couple months to tell him about the ongoing progress at Pennforest and to tell him about Burns’ close care of the children. 

Author’s Afterward:

Hundreds of thousands of children, in Pennsylvania alone, were subjected to the “State School and Hospital” institutions. Some patients suffered physical, sexual, and emotional abuse. In reality, there was no “Pennforest Model” to revolutionize the system. 

Civil cases began to expose the abuses in these facilities in the 60s, 70s, and 80s. Patient advocacy groups expanded at this time. In response to a variety of issues in the mental health system, beginning in the 1960s, the U.S. started to move away from institutionalization of individuals with significant mental health and developmental struggles. New treatments and community supports allowed most patients to function with outpatient treatment. De-stigmatization of mental health concerns also allowed these patients to integrate more into society. The Americans with Disabilities Act of 1990 codified this progress into law. 

This story is for my son, Harrison, and kids like him.