In 1841, a woman named Dorothea Dix walked into Massachusetts's East Cambridge Jail to teach Sunday-school classes to the female inmates there and was horrified at what she found. Mixed in with the criminals were what she'd call "idiots and insane persons," who were being mistreated and left to rot in the cells of a prison that wasn't designed to hold them.
Though women couldn't vote or hold office back then, Dix began a political crusade on behalf of the mentally ill. She toured the state's prisons and almshouses (as poorhouses were called) and found example after example of disturbed people locked in cages, chained, beaten, kept in solitary confinement for years, or cruelly neglected by their keepers. In an almshouse in Newburyport, she found a woman who had been locked in a tiny cellar under the stairs and a man who lived next to a "dead room" where corpses were stored. She recounted all this in a "memorial" note she sent to the Massachusetts Legislature in 1843 that called for "an asylum for this class, the incurable, where conflicting duties shall not admit of such examples of privations and misery."
Dix was at the leading edge of the first wave of mental health reformers in the US, who demanded that people suffering from mental illness be treated more humanely and less like animals. In the second half of the 19th century, mental institutions, many of them inspired by the writings of Thomas Story Kirkbride, were constructed in hopes of providing a place of refuge for the mentally ill.
"There is abundant reason why every State should make ample provision, not only for the proper custody, but also for the most enlightened treatment of all the insane within its borders," Kirkbride wrote in his influential 1854 work On the Construction, Organization, and General Arrangements of Hospitals for the Insane . "The simple claims of a common humanity… should induce each State to make a liberal provision for all its humanity."
That ideal of "enlightened treatment" deteriorated pretty drastically over the course of the following century, however. Asylums became overcrowded nightmares where the mentally ill were warehoused for years and "treated" with electroshock therapy and lobotomies. They started being referred to as "snake pits," after a 1948 film about a woman's terrifying time in a mental hospital. By the early 60s, a new breed of reformers began demanding the emptying of institutions that early mental health advocates like Kirkbride and Dix had fought for. The arguments were pretty clear-cut: Keeping people in asylums was expensive and cruel, and it wasn't even necessary thanks to new drugs, most prominently Thorazine, which could calm the psychotic and make it possible for them to pursue relatively normal lives.
So the mental hospitals let their patients go en masse in a process known as "deinstitutionalization." In many ways this was a major success, as thousands of mentally ill people became free of their oppressive institutional surroundings. Indeed, today the vast majority of the mentally ill lead perfectly ordinary existences and have no need of hospitalization. But many in the mental health field say this process went too far too fast, and that nothing grew up to replace the old snake pits, a view that has led to yet another wave of reformers who think it's time to bring asylums back.
Today the problems with the American mental health system are obvious to anyone who walks into a prison, as Dorothea Dix did 174 years ago, or visits a street where the homeless congregate. In New York, mentally ill inmates at Rikers Island have gotten into fights and been beaten by guards; in Washington State, a Department of Corrections psychiatrist told the Seattle Times in 2013 that 20 to 30 percent of inmates were mentally ill; cuts to mental health funding in Alabama and Minnesota have created severe shortages in services. Across the country, the problem is the same: There aren't enough services for the severely mentally ill who cannot take care of themselves, and as a result they wind up out in the cold. According to a 2014 USA Today article, the Department of Housing and Urban Development estimates that of the 610,000 homeless people living in America, 124,000 have a mental illness.
Earlier this month, VICE News released a video report on what is thought to be "the largest mental health care provider in America right now": Chicago's Cook County Jail, where approximately 30 percent of the 9,000 inmates have a mental illness. The concentration of the mentally ill in the jail has been helped along by cuts to state- and city-wide mental health services; because of this, Cook County Sheriff Tom Dart told VICE News, many bounce back and forth between the streets and jail, unable to care for themselves and falling through the system's widening cracks. The video shows one bipolar young man curled up alone inside a cell after visiting with a counselor who placed him on suicide watch—he's receiving some form of care, at least, but it's hard to imagine that he belongs behind bars.
"Honest to God, I can't think to myself that a thoughtful society would agree that this is how we should treat people," Dart told VICE News correspondent Danny Gold.
There was no single moment when it was decided that so much mental health treatment should happen within prisons and jails. Like many long-term public policy shifts that look flawed or damaging in retrospect, deinstitutionalization was a result of piecemeal decisions made at multiple levels of government over time—good or at least well-intentioned choices that add up to catastrophe.
The asylum population in the US peaked at 558,000 in 1955, and since then a series of moves has reduced the number of patients in state-run mental hospitals to 45,000. One of the most important of these moves, the Community Mental Health Act of 1963, promised that 1,500 small community mental health centers would be constructed—but this ideal never materialized.
"The program was never adequately funded by either the federal government or the states," Paul Appelbaum, a Columbia psychiatry professor and longtime critic of deinstitutionalization, told VICE. "Since then, a patchwork of programs has been created but never enough to meet the demand."
Another problem, according to Appelbaum, was that "the proponents of deinstitutionalization allowed ideology to trump their better judgment. Beginning with the perception that many people with mental illness did not need long-term hospitalization—which is absolutely correct—they came to conclude that almost no one needs longer-term care."
Over the years, many psychiatrists and others worried that deinstitutionalization had gone too far, too fast. Back in 1974, the American Psychiatric Association issued a position statement expressing concern that patients were being released "without adequate planning, which in turn results in their living in substandard and dehumanizing circumstances." In 1981, a New York Times editorial denounced deinstitutionalization as "a cruel embarrassment, a reform gone terribly wrong" because the mentally ill were not being properly cared for in the community. Even as the issue of severely mentally ill homeless people got more and more media attention in the 80s, the Reagan administration did little to address it, instead shifting the responsibility for funding and running community mental health centers to the states.
Some disagree with the broad narrative that deinstitutionalization has directly caused mentally ill people to become homeless or incarcerated. Mark Salzer, a psychologist and chair of the Department of Rehabilitation Sciences at Temple University, told VICE that the percentage of mentally ill people in prison didn't rise until the 80s, decades after the beginning of deinstitutionalization. The problem, he says, is that the war on drugs and other law-and-order policies ratcheted up the imprisonment of addicts and poor people, and the mentally ill are more likely than the general population to be poor or addicted to drugs.
"The police are arresting everybody who does certain things," Salzer said. "It's not just because they have a mental illness."
The problems faced by the seriously mentally ill have worsened thanks to the financial crisis leaving states with massive deficits, which many responded to by drastically slashing mental health budgets. Some experts think these sorts of cuts don't actually save money, since it costs more to treat the mentally ill in emergency rooms and put them in jails, but the sad truth is that there hasn't been much political will to fund programs that might help.
"The mentally ill are, by and large, a population that is darn close to voiceless other than some great advocacy groups that are really all that's left," Sheriff Tom Dart told VICE News.
"This was the original meaning of psychiatric 'asylum'—a protected place where safety, sanctuary, and long-term care for the mentally ill would be provided." —Dominic Sisti
This January, an op-ed appeared in the Journal of the American Medical Association with the subtitle "Bring Back the Asylum." In it, University of Pennsylvania bioethicist Dominic Sisti and his coauthors argue that it's time to return to the sorts of reforms suggested by Dorothea Dix: Instead of trying to treat the severely mentally ill and indigent in prisons, we should construct new hospitals where the few people who need inpatient treatment and structured, institutional-based assistance can get it. "This was the original meaning of psychiatric 'asylum'—a protected place where safety, sanctuary, and long-term care for the mentally ill would be provided," the authors wrote. "It is time to build them—again."
These would be state-of-the-art facilities with highly trained staff, Sisti told VICE—no lobotomies*, no snake pits. He said the use of the word asylum was meant to hearken back to Quaker ideals, which he described as "to basically respect individuals with mental illness as human beings, as persons with dignity, and to give them the safety and time they need to recover their lives."
The article touched off a cycle of controversy in the mental health community. Psychology Today and the New York Times published opinion pieces generally supporting the idea of more asylum-like institutions, which in turn inspired a series of letters to the Times, some of which expressed incredulity that cash-strapped state governments would be willing or able to build mental hospitals that wouldn't suffer from the same problems that plagued the last generation of asylums.
"Anyone who knows their history or understands their features appreciates that the original intent of 'asylums' cannot be achieved," Mark Salzer wrote in a rebuttal published on Philly.com. "They were never, and never can be, pleasant sanctuaries of healing."
Even if it was clear that more mental hospitals were necessary, it's not obvious how many more of them would be needed—or, more importantly, where the money to build them would come from. The broader issue is that across the country, mental health services remain underfunded and scattershot.
"Perhaps more than anything else, we need a vision," Paul Appelbaum said, "a comprehensive blueprint of an integrated system for mental health treatment that the states and the federal government can get behind and bring incrementally into existence."
What would that system look like? It might involve police officers specially trained to handle the mentally ill, a program that San Antonio has implemented with some success. It might feature centers that the mentally ill could be sent to rather than being warehoused in jails, as some state lawmakers in Minnesota have recently proposed. It would almost certainly mean improving the everyday lives of the mentally ill by helping them form connections within their communities. Salzer, for one, thinks that the US needs to embrace a more holistic model of mental health that works to help the mentally ill overcome common problems like poverty, isolation, and joblessness.
"If you have a lot of people who are unemployed and you're not doing anything about it, you're missing a great treatment opportunity, "said Salzer. "It's not all medications, it's not all case management, it's not all hospitals."
If you are concerned about the mental health of you or someone you know, visit the Mental Health America website.
UPDATE 4/27: An earlier version of this article implied that Dominic Sisti was against electroshock therapy when in fact, he believes it is "valuable for a certain population."
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