State hospitals still account for the majority of the state dollars spent on mental health care across the nation. Why do state hospitals persist and expand despite public scandal and professional disapproval? What role does the state mental hospital play in the current system of care for the seriously mentally ill? What role should it play, and at what cost? Dowdall explores recent efforts, successful and unsuccessful, to meet the increasingly elaborate standards imposed from without on the contemporary state mental hospital, and the impact of these efforts on the quality of care provided to its patients.