THE MENTAL HOSPITALS where the drugs revolution got its start represented a vast investment of social and intellectual capital. From the 1830s onward, the notion that prompt institutionalization represented the best or only response to serious forms of mental disturbance had become the ruling orthodoxy. On this foundation, states had been induced to spend large amounts of treasure to build and maintain ever-larger asylum systems to which the “insane” were consigned. The psychiatric profession at once emerged from the creation of the mental hospital and, for more than a century, ran and justified its existence. By 1950, more than half a million inmates filled the wards of state hospitals, and if any promise of cures seemed evanescent, the public had by now become thoroughly used to the idea that the proper response to psychosis was institutionalization.
Throughout its history, the asylum had had its critics. Some patients from the very outset proclaimed that the psychiatric emperor had no clothes, and that their confinement was a form of imprisonment.1 But they were easily dismissed, their credibility undermined by their status as mental patients. Muckraking journalists from Nellie Bly (Elizabeth Seaman), who in 1887 tricked her way into the Women’s Asylum on Blackwell Island in New York, to Albert Deutsch, whose exposés in The Shame of the States brought public attention to the deficiencies of these establishments just after the Second World War, exposed the scandals that lurked behind their facades, but the populations housed in them grew relentlessly year on year—until one day they didn’t.2
The decline in the hospital census was slow at first, but by the second half of the 1960s, it was rapidly accelerating. Between 1955, when the number of residents reached an all-time high of 558,922, and 1960, the inpatient census declined by just over 4 percent to 535,540. The next five years saw a slightly faster rate of decline, but the dramatic decrease took place between 1965 and 1980, when numbers fell from 475,202 to 132,164. By then, the remnants of the old institutions led, in the words of the Harvard psychiatrist Richard Mollica, a “lingering existence as demoralized and impoverished facilities.” Mollica warned of “a threatened disintegration of the public system.”3 Two decades later, the traditional mental hospital had virtually disappeared from the scene. So, too, had institutional psychiatry. All that had once seemed so solid melted into air.
In what must rank as an astonishing act of clairvoyance, the nineteenth-century British physician Andrew Wynter once speculated on what would become of the empire of asylumdom, at a time when it was rapidly expanding: “As we see wing after wing spreading, and story after story ascending, in every asylum throughout the country, we are reminded of the overgrown monastic system, which entangled so many interests and seemed so powerful that it could defy all change, but for that very reason toppled and fell by its own weight, never to be renewed. Asylum life may not come to so sudden an end but the longer its present and unnatural and oppressive system is maintained, the greater will be the revolution when it at last arrives.”4
As the decline of the asylum accelerated, the public was assured that deinstitutionalization constituted a grand reform. Patients who had languished on the back wards of mental hospitals were being returned to the community, thanks to the advent of modern drug therapy. The horrors of the madhouse were rapidly becoming a thing of the past. Community care would prove at once more humane and more effective. Mental hospitals were portrayed as places where social skills atrophied, the opportunity to make autonomous choices evaporated, and patients lost the capacity to cope with everyday life. They damaged rather than rehabilitated those they confined. A more tolerant and welcoming society would spare the mentally ill these dehumanizing effects of involuntary confinement and also provide an environment where, with skilled psychiatric assistance, they could live relatively normal lives. Jack Ewalt, chair of the department of psychiatry at Harvard, and his colleague Gerald Caplan were particularly active in spreading the doctrines of community care.
In 1964, Robert Felix, a former president of the American Psychiatric Association and the director of the National Institute for Mental Health from its foundation in 1949 until 1964, articulated the consensus of those who now called themselves “community psychiatrists”: “Many forms and degrees of mental illness can be prevented or ameliorated more effectively through community oriented preventative, diagnostic, treatment, and rehabilitation services than through care in the traditional—and traditionally isolated—state mental hospital.… [I]t will be possible to reduce substantially, within a decade or so, the numbers of patients who receive only custodial care—or no care at all—when they could be helped by the application of one or more of the modern methods of dealing with emotional disturbances and mental illness.”5 Embracing community care offered the prospect, Felix explained, “of ending forever the neglect and isolation which has been the lot of the mentally ill, both in and out of hospital, since the dawn of time.”6
It was a fairy tale. The decanting of mental patients into the community (and later the tightening of commitment statutes to make admission to the mental hospital increasingly difficult) took place with virtually no advance planning or provision for the housing or other needs of those with disabling mental illnesses. “Community care,” it transpired, was a shell game with no peas. In place of forcible confinement in publicly run asylums, the chronically mentally ill were abandoned to their fate.
ON ONE ACCOUNT, the demise of the state hospital and the rise of treatment in the community was the product of a simple technological fix. The advent of the new drugs for schizophrenia (and soon for depression as well) transformed the prospects for treating mental illness and made possible both the deinstitutionalization of patients already in the mental hospitals and the management of newer cases of mental illness on an outpatient basis. This was an account swiftly embraced by many psychiatrists, and it is still accepted in many quarters today. However, it ill accords with a careful analysis of these dramatic developments.
It is obvious that at the national level the first declines in state-hospital populations took place at the very moment when Thorazine (and its competitors) entered the marketplace. But temporal coincidence tells us little about causation. As it happens, a variety of data undermines the assertion that the introduction of psychotropic drugs caused the emptying of mental hospitals. In at least seventeen states, inpatient censuses had begun to decline between 1946 and 1954, a period when antipsychotics had not yet reached the marketplace. That pattern of extreme differences among states in the rate of discharge of mental patients persisted for at least a decade after the introduction of psychotropic drugs, with at least ten states experiencing increases in their inpatient populations during this period.7 This suggests that there was no immediate or necessary connection between the introduction of psychotropic drugs and the decline in mental hospital populations. Two contemporaneous studies that sought to understand how the two phenomena interacted reinforce that conclusion. The first is a series of papers by Henry Brill and Robert Patton that examined the decline in New York State hospital populations in this period, often cited as “proving” that drugs caused the decline. In reality, the papers demonstrate nothing of the sort. The authors note the temporal coincidence and then state that “we know of no other major change in operating conditions which took place between 1954–55 and 1955–56” that could have caused hospital populations to fall. But the other data they report undermine even this tautological statement, for they note that only a distinct minority of patients were given the drugs in this period, and there were wide variations in the proportions of patients receiving drug therapy (33.9 percent of women, for example, versus only 20.9 percent of men—yet again suggesting a greater willingness to experiment on women). And when they examined discharge statistics, they acknowledged that “no quantitative correlation could be shown to exist between the percentage of patients receiving drug therapy in a given hospital or a given category [of mental illness] and the amount of improvement in releases.”8
On the opposite coast, in California, state mental hospitals differed widely in how quickly they adopted the new drug treatment, and they kept records of which patients did and did not receive phenothiazines. L. J. Epstein and his colleagues were able to examine these detailed records, and, focusing on white male schizophrenics, they found that the relationship between drug treatment and release was a negative one. That is, patients given the drugs consistently spent longer in hospital than those who were not so treated. Both within and between hospitals, “the drug treated patients tended to have longer periods of hospitalization.” Hospitals that were the most enthusiastic adopters of drug treatment had lower discharge rates than those that were more cautious about the new drug therapy, and the evidence as a whole showed no relationship, they concluded, between drug treatment and “the more rapid release rate that has been observed in recent years.”9
A series of retrospective studies that subsequently explored this issue all came to essentially the same conclusion.10 In damping down the florid symptomatology of psychosis, drugs visibly affected the atmosphere inside mental hospitals, persuading psychiatrists that management in the community might prove possible. But the primary driver of deinstitutionalization lay elsewhere, in the loss of political support for mental hospitals and in changes in social policies brought about as limited postwar moves toward a welfare state changed the environment in which state policy makers operated.
IN THE UNITED STATES, the mentally ill had always been the responsibility of the individual states. The costs of housing and providing even minimal levels of treatment for this population were a huge burden on state budgets, and threatened to become an even more serious problem in the postwar period, as the old infrastructure crumbled and the unionization of state employees forced up costs. As long as mental patients were housed in state facilities, the federal government disclaimed all responsibility for them. But as the more astute and entrepreneurial states like New York and California began to realize (and as more backward states like Alabama more slowly began to appreciate, sometimes prodded by lawsuits), changes in the safety net provided by Congress dramatically altered this picture, providing an opportunity to transfer many of these costs off the state and local budgets and on to the federal government. In a famous case brought to federal court in the state of Alabama, Wyatt v. Stickney, members of the newly emerging mental health bar argued that patients involuntarily confined in a mental hospital had a right to treatment, which Alabama’s massively overcrowded state hospitals failed to provide. The judge in the case, Frank Johnson, endorsed this view and insisted that the state had to provide the minimum level of staffing laid down by the American Psychiatric Association. Governor George Wallace avoided a massive increase in staffing costs by simply discharging most of the inpatients, thus providing the ratio of staff to patients that the court demanded for those left behind in the institutions.
There were no improvements in drug therapy or dramatic breakthroughs in psychopharmacology in the period between 1965 and 1980, when the dramatic decrease in state-hospital populations took place. Indeed, well-placed observers have argued that there have been no major advances with respect to antipsychotic drugs all the way down to the present, a contention that will be discussed later in this book. There were, however, major innovations in social policy, and these are reflected very closely in the pattern that deinstitutionalization took in this crucial decade and a half.
As part of his Great Society program, and in the teeth of opposition from the American Medical Association, Lyndon Johnson secured the passage of Medicare and Medicaid, signing the bills into law on July 31, 1965. Primarily directed at the elderly, and secondarily at the poor, these benefits were not paid to any one resident in a state institution. As state bureaucracies came to realize, albeit not all at once, these funds could replace state expenditures on the mentally ill, provided patients were discharged from the state hospitals and placed elsewhere.
Looking at the period between 1965 and the early 1970s, what stands out is the huge fraction of discharged patients that came from the ranks of those over the age of sixty-five. Some states, like Wisconsin, passed legislation directly prohibiting the admission of those over sixty-five into state hospitals. Others simply adopted administrative policies that produced the same effect. Between 1955 and 1975, California cut the number of inpatients over the age of sixty-five by 94.6 percent. In 1969, Illinois appointed a new director of its department of mental health, a fiscal and management specialist. By September of that year the state mental health code had been revised to exclude most of the elderly, and plans were rapidly drawn up to discharge 7,000 to 10,000 elderly patients over an eighteen-month period. Massive discharges followed. The sequence was soon repeated in New York State, as part of a general shift of responsibility from the mental health system to the welfare system.11
Many patients were transferred from state-run and state-financed mental hospitals to private, profit-making nursing homes. Between 1963 and 1969 alone, the numbers of elderly patients with mental disorders living in nursing homes increased by nearly 200,000, from 187,675 to 367,586.12 By 1972, with some younger patients added to the mix, the mentally disturbed population housed in nursing and board-and-care homes had risen to 640,000, and two years later, it rose to 899,500.13
Younger patients only began to be discharged or diverted away from mental hospitals in large numbers following the addition of Supplemental Security Income (SSI) to the Social Security program. SSI provided a guaranteed income to those unable to work by reason of age or disability, and unlike Social Security, those payments did not depend on prior work history. Some ex-patients, less disturbed than others and victims of an earlier tendency to overhospitalize, were able to assimilate reasonably successfully back into society, but they were a distinct minority. Others initially returned to their families of origin. Isolated and without much support or advice, these families faced an onerous task. The afflictions and the misery they endured were largely hidden, not least because of their understandable desire to shrink from the stigma that so closely clung to mental illness. They quickly discovered that public authorities had failed to provide aftercare facilities and refused to countenance rehospitalization. In the long run, most families found the burdens all but intolerable, and these ex-patients and those who in an earlier era would have been hospitalized found themselves sharing the fate of the much larger group of those who had no family or whose relatives from the outset had refused to assume responsibility for them.
One consequence of this situation was the creation of a new group of institutions, reminiscent of the handful of private, profit-making madhouses that had emerged in eighteenth-century England to cope with the mentally disturbed, albeit on a far larger scale.14 Ownership of these twentieth-century equivalents of the madhouse—the nursing home, the board-and-care home, the welfare hotel—was open to all who possessed or could borrow the necessary capital and could negotiate or bypass certain licensing requirements. In an ironic twist, some of these “community” facilities were opened and operated by those who had previously worked on the back wards of the old state hospitals. Like their eighteenth-century forebears, these facilities largely operated free of state supervision or oversight.15
For elderly patients, the transfers often meant premature death.16 For many ex-patients, young and old alike, one set of institutions had been substituted for another, and the logic of the marketplace all but ensured neglect, for the less the operators of these facilities spent on the inmates, the larger their profits. State and federal payments to this burgeoning entrepreneurial class were in any event scarcely munificent, and at best it sufficed to purchase the most basic forms of subsistence care. As one contemporary study documented, “A typical day for a mentally ill person in a nursing home was sleeping, eating, watching television, smoking cigarettes, sitting in groups in the largest room, or looking out the window; there was no evidence of an organized plan to meet their needs.”17
Quite soon, the massive numbers discharged from or refused admission to the state hospitals exceeded the capacity of the nursing home system to absorb more bodies. Many of the chronically mentally ill thus found themselves in a variety of other, still less salubrious settings—group houses, foster-care homes, halfway houses, room-and-board facilities, and “welfare” hotels. Others began living on the streets, and the sidewalk psychotic became an increasingly familiar feature of the American urban scene.
For a time, as this new geography of madness established itself, it was possible to leave these lost souls to decay, physically and otherwise, in the most blighted portions of cities, essentially invisible to the better off. The first decades of deinstitutionalization thus entailed, according to one study of the move from the asylum to the street, “the growing ghettoization of the returning ex-patients, along with other dependent groups in the population; the growing succession of inner-city land use to institutions providing services to the dependent and needy … [and] the forced immobility of the chronically disabled within deteriorated urban neighborhoods.”18 Zoning laws were invoked to exclude such “undesirables” from places frequented by the “respectable classes,” though usually the costs of housing in these areas, and absence of social services, were sufficient to keep them out. The alleged advantages of community treatment were expected to materialize in areas with high crime rates, abandoned buildings and substandard housing, and a pervasive social anomie.
Such developments did not occur without implicit and sometimes explicit state sponsorship and encouragement. Remarkably, they persisted even when scandals erupted. In New York State, the corrupt links between the board-and-care industry and the political establishment eventually surfaced thanks to a New York Times exposé in 1975, forcing a full-scale inquiry and subsequent prosecutions.19 Pennsylvania, with remarkable foresight, repealed its provisions for inspecting boarding homes in 1967, the same year that it began “a massive deinstitutionalization program aimed at moving patients out of mental hospitals into community programs.”20 Hawaii faced a major shortage of beds in licensed boarding homes when it adopted a policy of accelerated discharge of mental hospital patients. The problem was solved, with unusual bureaucratic flexibility, through a proliferation of unlicensed facilities actively promoted by the state mental health department.21 Nebraska at first shied away from such a laissez-faire approach, deciding that some form of state oversight was called for. Accordingly, in a splendidly original variation on the ancient practice of treating the mad like cattle, the state placed the licensing of board-and-care homes in the hands of the state department of agriculture. Subsequent citizen complaints about the resultant conditions led to second thoughts about the desirability of taking official notice of the board-and-care operators’ practices, so the state withdrew the licenses, but not the patients, from “an estimated 320 of these homes, leaving them without state supervision or regulation.”22 Missouri simply noted the existence of some “755 unlicensed facilities in state housing more than 10,000 patients” and continued to dispense the funds on which their operators depended.23 Other states, like Maryland and Oregon, opted for perhaps the safest course of all—no follow-up on those they released and hence a blissful official ignorance about their subsequent fate.24 So it was that states all across the country abandoned the publicly funded asylums for a new form of privatized neglect.
A curious political alliance supported the dissolution of the state hospitals. On the left, a fierce opposition to the incarceration of the mentally ill in places that resembled prisons or warehouses for the unwanted, a profound skepticism of psychiatry’s claims to expertise, and a conviction that institutionalization dehumanized and damaged those caught up in its coils fueled a desire to abolish these Goffmanian total institutions.25 On the right, a libertarianism that hated the public provision of services of any sort, coupled with the promise of fiscal savings, made closure of state hospitals equally irresistible.26 And once asylumdom had essentially vanished from the scene, there was little chance there would ever be substantial support for its revival.27
ORGANIZED PSYCHIATRY WATCHED the dissolution of the vast establishments that had given birth to the profession in virtual silence. A few isolated voices raised an alarm about what the changes meant in practice, but these were few and far between. Thomas Reynolds, for example, who headed one subdivision of the vast federal St. Elizabeths Hospital in Washington, DC, warned that
if we examine the actual quality of the lives of these people we now return so easily to the community, in their homes and foster homes and halfway houses, taking their Thorazine tablets or their Prolixin injections, we will discover that the great majority, while outwardly sane and tractable, are living utterly barren and blasted lives.… We have created a kind of slow spiritual euthanasia with chemical agents, whose primary function is get the patients away from us so that by not seeing the poverty of their lives, we may cease feeling any responsibility for the matter.28
His warnings went unappreciated and ignored, and the situation soon became ever more dire.29
THE THOUSANDS OF PATIENTS who had once thronged the wards of the state hospitals had always been a visible reminder of psychiatry’s near-impotence when it came to managing severe and chronic forms of mental illness. The seriously psychotic had become a professional liability. Few professionals wanted to practice among such an impoverished, clinically hopeless clientele. Hence the alacrity with which the profession moved to distance itself from the socially contaminating effects of an overly close association with these wards of the state. Psychiatric involvement with the chronically disabled could in the future be limited to the periodic prescription of antipsychotic medications, often dispensed by others. In place of trying to cope with the problems of the seriously disturbed, socially deprived, often physically decrepit people who had previously languished on the back wards of state hospitals, psychiatry found it far preferable to minister to the needs of socially functioning patients (or at least those covered by insurance policies) who found themselves struggling with anxiety or depression or eating disorders; to children exhibiting moderate to severe behavioral problems; to the abused and abusive; and those trapped in the coils of substance abuse.
The welfare reforms (a euphemism for the retrenchment of the social safety net) that began in the Reagan years and have been a feature of the neoliberal consensus that has persisted ever since, under Republican and Democratic administrations alike, have in many ways worsened the problems confronting the psychotic. Programs like Aid to Families with Dependent Children were systematically dismantled, amid claims that they fostered dependence and did more harm than good. President Clinton’s welfare “reforms” limited lifetime benefits to five years, and in place of earmarked funds for particular programs, block grants to the states became the norm, weakening the social safety net even further. Where the market rules, the outlook is bleak for those unable or ill-equipped to fend for themselves.
Casualties of the hostility to social provision included the federal transfer programs that once underwrote and encouraged the neglect and destruction of state hospitals. These programs have become more restrictive and limited where they have not been eliminated altogether. State governments have lacked the resources and political will to ameliorate the situation to any significant extent, a problem exacerbated by the stigma attached to mental illness and the low priority accorded to programs for the chronically dependent.30 Funds that once paid for the miserable routines of the board-and-care homes have dried up. The number of people confined in mental hospitals in 2000 (54,836) amounted to less than a tenth of those in 1955, though in this period the population of the United States had increased by more than two-thirds. These numbers mask a drastic shift in the makeup of the institutionalized population, an ever-increasing proportion of which is composed of those with criminal justice histories (often committed by the courts based on incompetence to stand trial, or sex offenders whose sentences have expired but who are held in mental health facilities because they are deemed a continuing threat to the community).31 One can add to these a small group of patients too disabled to be discharged and also others who cycle through the system for brief periods before being dismissed, often back on to the streets from whence they came.
Though the mentally ill are scarcely the only source of the epidemic of homelessness that now characterizes urban America, they are a major component of the problem. Informed estimates suggest that they constitute as much as a quarter or a third of the homeless.32 In place of incarcerating inconvenient and often intolerable people who only incidentally violate the law in mental hospitals, twenty-first-century America has adopted a policy of repressively tolerating those who would once have been consigned to these establishments. For such lost souls, cycling between the streets and shelters, with periodic trips to jails when their behavior becomes too disturbing and threatening, has become a routine part of their existence. Tolerance of a sort (one that ignores the problems of the mentally disturbed and the burden they impose on the urban social order) alternates with repression, and then more tolerance, better described as neglect. On occasion, a brief trip to a psychiatric ward is thrown into the mix, where medications are adjusted in an attempt to damp down florid symptomatology. But discharge is rapid, followed by a return to the streets.
The largest providers of psychiatric services, if that is the correct descriptor, have become carceral institutions such as the Los Angeles County Jail, Rikers Island in New York, and the Cook County Jail in Chicago.33 Citing figures supplied by the Los Angeles County Sheriff’s department, Joel Braslow and his colleagues indicate that, on an average day, more than 5,000 prisoners with serious mental illness are housed in the Los Angeles County Jail, making it the world’s largest psychiatric institution.34 African Americans constitute “9.6% of the county’s population, yet they constitute 31% of LA County jail prisoners, and 43.7% of those diagnosed with ‘serious mental illness’ requiring special jail housing.”35 Those statistics hint at the persistence of the differential treatment of mentally ill patients by race that has a history that extends all the way back to the asylum years, and that has undoubtedly been exacerbated by the collapse of public provision for the social consequences of serious mental illness.
Racial disparities have been shockingly understudied when it comes to contemporary mental health issues, though there is evidence that these figures from Los Angeles are part of a larger pattern: Blacks are disproportionately affected by this warehousing of the mentally ill in jails, part of the larger discrimination that pervades the criminal justice system.36 One would like to know whether drugs were and are disproportionately prescribed by race. But mental hospitals stopped collecting racial data in the mid-1950s, just as the psychopharmaceutical revolution got under way. In the words of one scholar who has focused on mental illness in urban environments, “The inaccessibility of patient records [for privacy reasons] places limits on the archival evidence. Unfortunately, any racial differential in the use of chlorpromazine and reserpine must remain speculative.”37 The dearth of serious research on the subject is itself a telling commentary on the neglect of the social dimensions of serious mental illness that has characterized the last four decades.
Black Americans disproportionately lack social and financial capital—indeed, the differences in wealth are extreme.38 Their access to decent housing and health care is sharply restricted.39 All too many of them live in deprived neighborhoods and have little control over their life circumstances.40 Black men are incarcerated at seven times the rate of white men: one in fifteen over the age of eighteen is in jail or prison.41 And both adults and children are systematically exposed to higher levels of trauma: emotional or physical neglect and abuse; parental separation or death; witnessing or suffering from gun violence; not to mention violence at the hands of the police.42 Recent research has suggested that the concatenation of these problems has profound implications for the mental health of Black Americans.43
In the early stages of deinstitutionalization, a policy of neglect was largely invisible to the better-off among us. Unwanted and unloved, discharged patients lived an appalling existence in the blighted regions of our cities, where they were left to decompose in areas the well-to-do studiously avoided. But their numbers have grown. It is no longer possible to contain them in the skid rows and ghettoes of our urban centers. On the contrary, their presence is now all too visible to the more fortunate members of our society, for whom they represent a recurrent source of nuisance, alarm, and danger. Though the situation has provoked some political backlash, as yet it has not prompted any major new policy initiatives or even plausible proposals about how to respond to the problems we confront. Deinstitutionalization continues to define public policy toward serious forms of mental illness, notwithstanding the cumulative evidence of its disastrous impact on the lives of many of those supposed to benefit from it.44
Under the circumstances, it should come as no surprise to learn that those afflicted with serious mental illness have a life expectancy of between fifteen and twenty-five years less than the rest of us.45 “Community care” has turned out to be an Orwellian euphemism masking a nightmare. That is a disturbing commentary, not just on the failures of American psychiatry but on the politics and priorities of twenty-first-century America.