In this series
In this series
Let’s look at the reasoning, and numbers, of deinstitutionalization—America’s mid-century policy of moving the mentally ill population out of large hospitals of widely varying quality and into home-based care and community integration.
In 1955, state mental hospitals housed 559,000 patients. That number dropped by 80 percent during the next three decades and then dropped further. Seven decades later, the US population has more than doubled to 343 million, but on any given night, only about 37,000 people are in state psychiatric beds.
Those state psychiatric hospitals shed their patients for many reasons, but perhaps the most important was that medical hopes were high. Insulin could treat diabetes, and antibiotics could be lifesavers regarding physical disease: Why not the same for mental disorders? To fight manic episodes, use lithium. To fight clinical depression, add “feel good” transmitters. Some of the older asylums had been brutal to residents, and visions of humane medical management of mental illness naturally appealed to reformers.
Politics played a role too. American Psychiatric Association president Harry Solomon proposed in 1958 that state mental hospitals be “liquidated as rapidly as can be done in an orderly and progressive fashion.” Orderly. Progressive. That optimism combined with Washington ambitions to expand federal control—which could come only if state mental hospitals closed.
Psychiatrist Bertram Brown, who became head of the National Institute of Mental Health (NIMH) in the 1970s, frankly said, “The power structure of mental health was the state hospital superintendents and the state commissioners. … That was the system we had to break in order to have a community mental health system.” Community mental health: Those formerly institutionalized could live as everyone else did in their own homes, taking their meds.
State legislators did not object, not least because mental hospitals were such a big part of their budgets. They could also go with the flow of an anti-institutional tsunami sweeping through American society during the 1960s. Thomas Szasz’s The Myth of Mental Illness (1961) declared that psychiatric labels were largely ways to constrain troublesome people and involuntary hospitalization was imprisonment.
That same year, Erving Goffman’s Asylums suggested that many people in state mental hospitals were perfectly sane—or, at least, would be if they lived somewhere else. He equated mental health hospitals with orphanages, prisons, and even concentration camps. He said treatment “mortified the self”: By stripping residents of their prior identities, asylums made people insane.
In 1962, Ken Kesey’s novel One Flew Over the Cuckoo’s Nest —which became a film that won all five major Oscars in 1976—popularized that concept. And R. D. Laing’s The Politics of Experience in 1968 argued that those called crazy were the sane ones in a mentally ill world.
Sociologist Christopher Jencks saw it differently, complaining in The Homeless that advocates “thought individual autonomy so important that they could hardly imagine patients who would be better off when other people told them what to do.” Jencks had in mind people who heard voices or noises that others could not hear, saw things others could not see, thought they had special powers, or felt their mind was taken over by external forces.
New medications helped some such people, but the “psychiatric revolution” proved overrated. M. Brewster Smith, a leader of the Joint Commission on Mental Illness and Health that Congress created in 1955, soon acknowledged that “Extravagant claims were made. … The professional community made mistakes and was overly optimistic, but the political community wanted to save money.”
Another commission leader, Charles Schlaifer, said, “Tranquilizers became the panacea for the mentally ill. … State programs were buying them by the carload, sending the drugged patients back to the community and the psychiatrists never tried to stop this.”
Besides, the meds were only useful when taken, and many people who are homeless and mentally ill suffer from anosognosia, the disease of not knowing you have a disease. As The New York Times has reported, “Without supervision, many confused and frightened former patients do great harm to themselves by failing to fill their prescriptions for the tranquilizers and antidepressants that help control the more bizarre symptoms of their illnesses. When their behavior becomes violent, they may end up in the psychiatric wards of the city’s hospitals—but only if they pose an immediate danger to themselves or others.”
What counts as “immediate danger”? Psychiatrist E. Fuller Torrey wrote in Nowhere to Go, “In the District of Columbia, I have personally asked police to commit an overtly psychotic woman who was walking the streets carrying an axe; they refused, saying that she had not done anything with her axe.”
The New York Times in 1979 described those housed in one homeless shelter: “By and large, they come from New York State’s psychiatric hospitals, which have released 83,659 adult patients ‘to the community’ over the last four years—nearly 40,000 of them to New York City.”
The headline of that story stated, “Mental‐Patient Release Program Leaves Many to Face Harsh Fate.” But it wasn’t fate: It was cultural pressure, budget pressure, and medical arrogance. As Robert H. Felix, director of the National Institute of Mental Health, admitted: “We psychiatrists … didn’t ask the questions that should have been asked when developing a new concept, but psychiatrists are human, too, and we tried our damnedest.” In the same article, John A. Talbott, president of the American Psychiatric Association, blamed “wishful thinking.”
The American Psychiatric Association in 1984 officially acknowledged that discharging mental hospital patients and closing those facilities had been “a major societal tragedy,” for “hardly a section of the country, urban or rural, has escaped the ubiquitous presence of ragged, ill and hallucinating human beings, wandering through our city streets, huddled in alleyways or sleeping over vents,” being “regarded as an eyesore at best and the victims of a moral scandal at worst.”
And in 1987, a New York Times editorial described “the ragged man shuffling through the bus terminal … the wild-eyed woman bundled in sweaters and coats on a 90-degree afternoon: Such are the pathetic symbols of failed mental health policy.” Following policy change from the New York mayoral office, the paper said, the number of mentally ill homeless people “roaming the streets in fear and fantasy” had apparently “increased sharply. All need help; few ever get it.”
They were unable to speak up for themselves.
