Saber-rattling about homelessness is nothing new for America’s mayors, but Eric Adams has escalated this rhetoric dramatically in the past couple of months. The mayor of New York is using genuine concern over the plight of unhoused people with mental illness to launch a new round of police sweeps, this time with a twist: people whom the police judge to be severely ill and incapable of caring for themselves will be involuntarily hospitalized. Demands to expand involuntary treatment and involuntary hospitalization are also coming from California.
The United States has barely any public mental health infrastructure, and as a result people with mental illnesses are often shunted into the prisons or onto the sidewalks. The largest mental health facility in the United States is the Twin Towers Correctional Facility in Los Angeles. Meanwhile the number of unhoused people with severe mental illness is often inflated, but nevertheless tragically high: at least 25 percent of those forced to live on the street have a diagnosis of a severe mental illness, and many more likely qualify even if they’re undiagnosed.
People across the political spectrum understand that our current system is ineffective, though they bring different levels of compassion to their analyses of the situation. Conservatives are primarily concerned with disappearing populations that they consider to be a nuisance and a menace. Most liberals understand that leaving people to suffer on the streets is inhumane, while treating people in jail is more expensive than simply doing so in a hospital — and both are profoundly traumatizing. But despite their differences, conservatives and liberals are increasingly united in their calls to return to the bygone era of mass involuntary hospitalization.
This is a mistake. In cyclical fashion, mental health reformers have promised that, due to the advent of some new technology or modality, mental illness could be cured, or even prevented from occurring in the first place. When these hopes are inevitably dashed, society falls back on warehousing people and keeping them out of sight. We now find ourselves close to a bipartisan embrace of the latter option. To understand what’s wrong with this approach and break us out of the cycle, we must reexamine why deinstitutionalization unfolded the way that it did in the mid-twentieth century — culminating with Ronald Reagan famously closing the mental hospitals — and where it went wrong.
There was never a social safety net in place to support deinstitutionalization. Looking forward, we must commit to trying something we’ve never seriously attempted: building up the welfare state.
The Birth and Death of the American Asylum
The modern mental asylum system began in hopes that it would serve as a cure. Reformers believed that building hospitals away from cities and giving the patient population agricultural work would help them to overcome their diseases, part of a broader framework of so-called “moral treatment.” How effective this ever was is up for debate: supporters like Thomas Kirkbride claimed very high cure rates that were probably inflated. And even Kirkbride maintained that hospital population sizes should be kept small, advice that was ignored.
In the nineteenth and mid-twentieth centuries, asylum populations were very diverse. People with schizophrenia and bipolar disorder, elderly patients suffering from dementia and Alzheimer’s, people with neurosyphilis, LGBT people, and those with substance abuse disorders were all a housed together in mental hospitals. Cities and counties saw the hospitals as a way to rid themselves of people they did not want to be responsible for, and institutions soon exploded in size. By the mid-twentieth century, approximately five hundred thousand people were held in hospitals in the United States, and as the population continued to grow, the institutions were placed under ever greater strain.
Asylums were not equipped to handle overcrowding, leading to mistreatment and genuinely horrifying conditions for the people forced to live in them. Understaffed hospitals relied on patient labor in order to function; at Oregon State Hospital in 1942, a patient working in the kitchen confused powdered milk with cockroach poison and served it to patients, killing forty-seven people and poisoning hundreds more. Exposés of places like Byberry Hospital in Philadelphia revealed nude patients crowded together and raw sewage filling the hallways.
These revelations created outrage, but by themselves did not lead to change. Psychiatric medications and the prospect of a cure proved to be the missing piece necessary for reform. Doctors had previously tried to find new ways to treat the patients that they had, ranging from electroconvulsive therapy to insulin-shock therapy (repeatedly inducing a diabetic coma in the hopes that it would cure schizophrenia) and lobotomization, but these had failed. The development of Thorazine (chlorpromazine) in 1951 and subsequent testing showed that many people’s symptoms improved by using the drug. Thorazine meant that psychiatrists who previously had been forced to work as caregivers could be given a more medical role, which helped to fully medicalize mental illness. It was a disease, and drugs were the cure.
Antipsychotics also helped create a full movement toward deinstitutionalization. Reformers whose intentions were genuine hoped to finally end the abuses that were so rampant in the hospitals and allow people to live with dignity. Some hoped that with treatment in the community, coupled with miracle drugs, mental illness could be cured or even prevented altogether.
A federal Joint Commission on Mental Illness and Health recommended in 1962 that all state hospitals be limited in size and gradually converted into care centers for any and all chronic health conditions. The focus would then be on community treatment. The Community Mental Health Act of 1963 offered federal funds to develop centers, and was sold in part on the promise that these centers could actually eradicate mental illness before it took root. Signed by John F. Kennedy just before his assassination, the bill promised to treat people where they lived and return them to “a useful place in society.”
For budget-conscious politicians who were also increasingly tired of dealing with the scandal-ridden hospitals, this approach seemed like a way to free themselves, especially with the federal government willing to shoulder more of the burden. In the 1960s, California’s mental hospital system was the second-largest outlay of state expenditures; only the university system cost more. The Lanterman-Petris-Short Act, one of the landmark deinstitutionalization bills in the country, was in part designed to shift costs to counties and federal entitlement programs like Medicaid and away from the state. It did so by dramatically limiting the scope of involuntary commitments so as to empty hospitals and lead people into community treatment centers, and it was widely copied by other states.
The reality of this process was a good deal messier than reformers had hoped. The exact effectiveness of antipsychotic drugs is bitterly debated and will likely continue into the future, but by themselves they are not the magic cures people hoped they would be. Counties and states were loath to pick up the financial burden of paying for additional care, meaning that community treatment from their end was underfunded. This has continued to the present day; during the Great Recession public spending on mental health declined precipitously. On the federal side, community mental health centers were slow to build and had such a broad mandate that people discharged from long-term hospitalization had difficulty getting treatment. Reagan did gut federal mental health expenditures, but he was not unique when it came to cutting mental health care: Democrats like Michael Dukakis, then governor of Massachusetts and the 1988 Democratic presidential candidate, did so at the state level, too.
Reformers who advocated for the closure of hospitals in good faith believed that people, once discharged, could quickly and easily integrate into the rest of society. Setting up any kind of social safety net never seems to have been a priority, and the ramshackle network of group homes and supported housing that exists has never been adequately funded. Architects of this system like Robert Felix conceded that they had oversold how easily it could be accomplished.
Instead of returning to mass forced hospitalization, we need to revise what we expect from deinstitutionalization. The deinstitutionalization framework is flawed because it has never incorporated the need for a broad social safety net. Proponents of deinstitutionalization dramatically underestimated even the medical care that would be available to people once they were discharged — let alone supportive housing, employment, and access to welfare.
The policy was sold in part based on the hope that magic drugs would solve the problem. Long-term care was never part of the deal, so when it proved to be necessary the new system was ill-equipped to provide it.
To break out of this rut, especially as our society seems to be moving even further toward a disastrous carceral care model, requires building up systems of long-term care, as well as systems of housing and employment. This means no longer hiding the problem or warehousing it, but it also means moving away from optimistic hopes for quick-fixes and cures.