No, we do not want to bring back asylums (but we never 'really' got rid of them).
Written by: Stefanie Kaufman
CONTENT WARNING: discussion of ableism, institutions, prison systems, psychiatric abuse, sterilization, lobotomies, graphic images
For years, mentally ill folks, disabled folks, and neurodivergent folks have been screaming into the void that linking mass shooting and mental illness was dangerous and life-threatening for our communities. Now, the folks in power (including POTUS/45) are advocating for institutionalization and asylums to make their way back into our society. And our communities are saying: HELL NO.
In POTUS's words:
"Years ago, we had mental hospitals, institutions... & a lot of them have closed. Some people thought it was a stigma... today, if you catch somebody, they don't know what to do with him. He hasn't committed a crime, but hey may very well & there's no mental institution."
First: No, we do not want to bring back asylums.
Disabled folks fought incredibly hard for their right to live in the community.
As s.e. smith stated on Twitter:
"Demonising mentally ill people will not fix the gun crisis in the U.S. Moreover, it's also paving the way to preemptive institutionalization: You're crazy, so you MIGHT kill someone. Psych holds are already a thing. So is forcible medication via Laura's Law. Don't know what it's like to walk into an ER in crisis while carefully calibrating your words to avoid an involuntary hold? Probably keep 'mental illness' out of your mouth. Some of us live with these risks *every day* while knowing the biggest danger we pose is to ourselves. 2/3 of gun deaths in the US are suicides. But let me remind you that POTUS just bemoaned the closure of institutions under Reagan in the 1980s and suggested that we should be able to incarcerate mentally ill people because we 'may very well' become mass killers even if we haven't done it yet."
And let's not forget, as Dr. Elena M. Chandler (@vrolijk5) reminded us on Twitter: "The Nazis warmed up by killing close to 100K disabled people and sterilizing an additional 400K. The administration is following the Nazi playbook."
Let's go back to mid-19th century America:
In the mid-19th century, there was an increased call for collective/social responses and an increase in the purview and power of different public health interventions. Individuals and communities began asking the question - Should there be some institution for people if their families can no longer take care of them? In addition, a large scale transition to urban life called for the development of institutions, as family units were beginning to separate and break down. The state took on an increasing role in the care of the mentally ill, and turned to commitment and confinement as solutions for the problem at hand. It is also important to note that this system was not standardized by any means, and consisted of ‘a patchwork of state and local responses’ (that one could surely manipulate depending on their position in society).
In terms of the science surrounding mental illness and psychiatry, medicine as a whole during the 19th century was shifting towards linking specific organs with specific behaviors; and finding biological roots for all causes of illness. Despite this increasing specificity, the term insane held great depth; and could define a wide variety of folks -- from epileptics, to manics, to depressives, to neurotics, etc. As Sara Newman describes in Disability and Life Writing Reports from the Nineteenth-century Asylum, “insanity characterized individuals outside the norm and incapable of managing their own lives”. When one is incapable of managing their own life, they become a burden of family members or friends; giving way to the establishment and pathway to confinement.
It's also critical to note who becomes victim of confinement. In Robert Roth's Sex-based Discrimination in the Mental Institutionalization of Women, he discusses how it was much easier to admit women than men to asylums; and ironically enough, easier for men to leave than women. In terms of admissions, gendered stereotyping came heavily into play, and men experienced great “sympathy and protectiveness towards women”. Though most women were pathologized, their circumstances and responses seemed fairly reasonable.
In her expose (10 Days in a Madhouse) of Blackwell Island's Insane Asylum, investigate journalist Nellie Bly described a fellow sister named Anne Neville, who essentially was sick from overwork. Her nephew, a waiter, was temporarily out of work and unable to afford her expenses at her Home (thus initiating Anne's transfer to Bellevue). Bly asks Anne, "Is there anything wrong with you mentally as well?" - to which Anne replies, "No. The doctors have been asking me many curious questions and confusing me as much as possible, but I have nothing wrong with my brain." Bly then asks, "Do you know that only insane people are sent to this pavilion?” “Yes, I know; but I am unable to do anything. The doctors refuse to listen to me, and it is useless to say anything to the nurses”.
Bly’s piece does an excellent job at portraying the important impact of intersections in identity, such as citizenship (or immigration status), class, education, race, and language abilities. As Roth further describes, “dynamics of power and status affect all mentally ill people … [and] behavior is often a consequence of limited social opportunity”.Roth also describes the important intersection between economic power and insanity: “Persons in an inferior economic position are vulnerable to institutionalization. In American society, fewer women than men work, and even fewer hold positions of respect and authority, or are the sole supporters of their family. Society has less opportunity and less motivation to intervene with a man supporting himself and his family”. This disparity increases greatly if a women does not speak English well, or is an immigrant, for example.
When reading the account of Nellie Bly, it is difficult to imagine that these asylums are set up to help anybody. As Bly famously exclaims, “What, excepting torture, would produce insanity quicker than this treatment? I would like the expert physicians … to take a perfectly sane and healthy woman, shut her up and make her sit from 6 A. M. until 8 P. M. on straight-back benches, do not allow her to talk or move during these hours, give her no reading and let her know nothing of the world or its doings, give her bad food and harsh treatment, and see how long it will take to make her insane”. In Bly’s own account, the conditions of the insane asylum were producing insanity; not treating it.
As Sara Newman summarizes, “In all, those who do not conform in thought, action, and physical appearance are locked away from the world. Because the world is crazy and run by distorted people, the world is a kind of self-perpetuating asylum; everyone is an inmate who abuses those less powerful … The inmates’ experience of cruelty leads them to question who is insane and, in turn, characterize their oppressors in their own terms”. The asylum thus becomes a convenient place to ship those who could no longer be taken care of by family members, hospitals, or boarding homes; and was not reflective of the ‘true’ insane who needed caretaking."
And second: Deinstitutionalization is a myth.
(A Review of History)
Mass institutionalization is not a threat of the future -- it is already here: The prison system is the largest mental health provider in the United States.
- Roots of consumer movement: folks began writing about their experiences
- Early pioneers brought to light their outrage at the indignities and abuses they had experiences inside psychiatric hospitals
- Marked the beginning of the deinstitutionalization movement- meant to invest $$ in community-based solutions to eliminate institutions [this never happened]
- More folks released from hospitals & creating informal relationships in the community
- Civil Rights Movement inspired former patients to become better organized into the mental patients’ liberation movement
- Groups of consumers saw themselves as being rejected by society and robbed of power & control over their lives.
Source: Project LETS PMHA Training
Benjamin Rush (1745-1813)
Now we’re going to go all the way back in time to figure out how we ended up here! Keep in mind: we have reduced over 200 years of history, so we will not cover everything- and there are definitely gaps. This is also an incredibly US-centric look at "deinstitutionalization."
Benjamin Rush is considered to be the Father of American psychiatry. His portrait is actually on the emblem for the American Psychiatric Association. He advocated for insane asylums, and believed in a cure. He also advocate for forced psychiatric treatment. His preferred method? The spin chair (pictured to the right).
Dorothea Dix (1802-1887)
Dorothea Dix was a Boston schoolteacher who visited the East Cambridge Jail, where she first saw the horrible living conditions of the mentally ill. Believing they could be cured, Dix lobbied lawmakers and courts for better treatment until her death in 1887.
Her efforts lead to the establishment of 110 psychiatric hospitals by 1880. However, asylums were changing from small, therapeutic programs into large, custodial hospitals- which was not the vision of Dorothea Dix.
Nellie Bly (1887)
On assignment for New York World, Nellie Bly feigns lunacy in order to be admitted to the Women’s Lunatic Asylum on New York’s Blackwell’s Island. Her exposé, “Ten Days in a Mad-house,” detailing the appalling living conditions at the asylum, leads to a grand jury investigation and needed reforms at the institution.
Era of the Asylum (1850-1950)
Many believe psychiatric treatment was at its lowest point during this time period. There was a prevalent eugenic ideology- meaning humans who were mentally ill were genetically inferior to others and should not be allowed to procreate to avoid polluting the gene pool.
Additionally, pseudo-science predominated with virtually no control over what kinds of treatment patients received: insulin shock, ECT, lobotomy, and hydrotherapy.
100 years of state-based approaches led to long-term institutional care; large hospitals; and a focus on custody (management and containment) rather than treatment. By the mid-1950s about 560,000 Americans resided in state supported institutions. The average length of stay was measured in years. Many spent their entire lives in asylums- which is really tremendous to think about.
Indiana Eugenics Law (1907)
Indiana becomes the first of more than 30 states to enact a compulsory sterilization law, allowing the state to “prevent procreation of confirmed criminals, idiots, imbeciles and rapists.” By 1940, 18,552 mentally ill people are surgically sterilized.
The lobotomy (1936)
Dr. Walter Freeman and his colleague James Watt perform the first prefrontal lobotomy. By the late 1950s, an estimated 50,000 lobotomies are performed in the United States.
It’s important to note that many folks in the medical community did NOT agree with Freeman’s methods, but it was considered unethical at the time to publicly criticize another medical professional (as a doctor). This is really important to think about- and can help understand why many folks have a mistrust of the medical system.
It is related to a broader context of research and medicine- it’s also important to bring up individuals like Henrietta Lacks, and the Tuskegee experiments. These betrayals and abuses of Black bodies remain (rightfully so) as a barrier for many Black Americans in the United States.
LIFE Magazine Expose (1946)
Source: Journalistic exposes: Life Magazine- Bedlam in 1946 [Pennsylvania’s Byberry & Ohio’s Cleveland State]
“All of a sudden America sees these photos that look like concentration camp photos. You see people huddled naked along walls, strapped to benches... and it really is this descent into this shameful moment.”
(Robert Whitaker, Author of “Mad in America”)
This was really the first time a large-scale, well-known magazine documented what was
occurring in psychiatric institutions- and it was an incredibly important piece.
Marketed as Thorazine by Smith-Kline and French, chlorpromazine is the first antipsychotic drug approved by the Food and Drug Administration (FDA). It quickly becomes a staple in asylums.
Thorazine was also originally marketed as the “oral lobotomy”- and was a major factor in deinstitutionalization. It allowed folks to manage their symptoms and be docile enough to integrate back into the community.
As we mentioned, thorazine and the exposes were huge factors. Additionally, mental health began to make its way into the federal conversation with President Eisenhower. Something important to mention is the introduction of Labeling Theory which refers to the idea that psychiatric labels did not possess an inherent truth- but were simply helpful categorizations.
It’s also really important to note that the term deinstitutionalization isn’t necessarily real- as it never happened. A more accurate term is transinstitutionalization- in which mentally ill folks were translocated to prisons and homeless shelters.
Community Mental Health Act (1963)
President John F. Kennedy signs the Community Mental Health Act to provide federal funding for the construction of community-based preventive care and treatment facilities- which ended
109 years of federal noninvolvement in state services for the mentally ill.
Congress, however, refused to authorize funds to hire staff for CMHCs and less than a month later, President Kennedy was assassinated. The program was never adequately funded.
It’s important to note that in reality, CMHC’s offered treatment to new groups of previously untreated, acutely ill, and emotionally troubled patients. Few persons with severe and chronic illnesses were treated (which was the goal of deinstitutionalization).
States are incentivized to move patients out of state mental hospitals and into nursing homes and general hospitals because the program excludes coverage for people in “institutions for mental diseases.” This was more influential than CMHC’s or psychotropic drugs; and the locus of care became nursing homes because of generous federal payments (Medicaid). In effect, states were cost-shifting the burden of care for people with serious mental illness to the federal government.
Failure to Meet Goals (1975)
Surprise- deinstitutionalization didn’t work! After 1975, no new construction was attempted and federal dollars were reduced. Most community mental health clinic’s focused on prevention & crisis services; severely mentally ill folks did not receive follow-up services necessary to live in the community; and there was no guidance on relationships with existing psychiatric hospitals- which led to fragmentation of services and no continuity of care. Essentially, it was a shit show.
CMHC’s and Deinstitutionalization
Between 1955 and 1980, populations of state hospitals dropped from 558,000 to 140,000. But where did they go? They became poor, homelessness, criminalized, and committed to nursing homes.
Government funds did NOT provide patients with shelter, housing, and treatment; and there was a rise in general hospitals adding specialty psychiatric wings.
Mental Health Systems Act (1980)
In 1980, President Carter attempted to restructure the community mental health programs and bring a new focus to seriously mentally ill folks- but ...
Ronald Reagan (1981)
Reagan passed OBRA (the Ombuds Budget Reconciliation Act) which repealed Carter’s community health legislation and established block grants for states(decreasing federal spending on mental health by 30%). Reagan’s decision ended all federal initiatives of the previous 18 years, closed all NIMH offices across the country, and made it nearly impossible for community clinics to remain open. Thanks, Reagan.
Streets & Cells (2000s)
“Nowhere in our society is the debacle of deinstitutionalization felt more than in our criminal justice system. America’s jails and prisons are now surrogate psychiatric hospitals for thousands of individuals with the severest of brain diseases.” - Treatment Advocacy Center
Prison-Industrial Complex (2004)
Studies suggest approximately 16 percent of prison and jail inmates are seriously mentally ill, roughly 320,000 people. This year, there are about 100,000 psychiatric beds in public and private hospitals. That means there are more three times as many seriously mentally ill people in jails and prisons than in hospitals.
Bly, Nellie. “10 Days in a Madhouse.” New York: Ian L. Munro, 1887.
Newman, Sara. "Disability and Life Writing Reports from the Nineteenth-century Asylum." Liverpool: Journal of Literary & Cultural Disability Studies, 2011. 261-278.
Roth, Robert T., and Judith Lerner. "Sex-based Discrimination in the Mental Institutionalization of Women." California: California Law Review, 1974. 789-815.