The Cult Dossier · No. 163 · Psychiatry / The Asylum
Deinstitutionalisation
The Community Mental Health Act; transinstitutionalisation
1955 – present · United States, with parallels across the developed world
XV. THE ASYLUM — WHEN MEDICINE DECIDED WHOSE MIND WAS WRONG
None.
Who led it
No single author. The instruments were the arrival of chlorpromazine in 1954, the COMMUNITY MENTAL HEALTH ACT signed by PRESIDENT JOHN F. KENNEDY on 31 OCTOBER 1963, and a long sequence of state budget decisions.
What it worshipped and taught
That large state hospitals were inhumane and unnecessary, that antipsychotic medication made community life possible, and that a national network of local mental health centres would take over their work. THE FIRST TWO PROPOSITIONS WERE LARGELY CORRECT. THE THIRD WAS NEVER FUNDED.
Who was in it
John F. Kennedy, whose sister ROSEMARY had been lobotomised in 1941 (see 158); the state legislatures that closed the hospitals; the county jails that received the population.
How it ended, or where it stands
THE ASYLUMS CLOSED AND THE POPULATION DID NOT DISAPPEAR. It moved. The era that began by building institutions for the mentally ill ended by using the criminal justice system as one, without ever calling it that.
The dead
Not quantified here. Excess mortality among the severely mentally ill outside institutional care is well documented; this file does not attach a number to it.
Of note
THIS IS WHERE THE ERA CLOSES, AND IT CLOSES IN A CIRCLE.
DOROTHEA DIX began in 1841 by walking into a jail and finding mentally ill people held in dark, bare cells (155). She spent forty years getting them hospitals. THOSE HOSPITALS WERE CLOSED, AND THE POPULATION RETURNED TO THE JAILS. The measurable outcome of the whole two-century project is that there are now roughly ten times as many severely mentally ill people in American correctional facilities as in psychiatric hospitals.
THE ARGUMENT IS NOT THAT THE ASYLUMS SHOULD HAVE BEEN KEPT. Read 153, 158, 159 and 160 together and the case for closing them is overwhelming. THE ARGUMENT IS THAT CLOSING THEM WAS THE ONLY HALF OF THE PLAN ANYONE PAID FOR. Deinstitutionalisation is not a story about a bad idea. It is a story about a good idea that was implemented at exactly fifty per cent, and about which half a legislature will fund when the other half has no constituency.
KENNEDY'S SIGNATURE ON THE 1963 ACT IS THE DETAIL THAT BINDS THIS ERA TOGETHER. His sister ROSEMARY had been lobotomised at twenty-three, on their father's arrangement, and institutionalised for life (158). The man who set out to empty the asylums had watched what they were for.
DOROTHEA DIX began in 1841 by walking into a jail and finding mentally ill people held in dark, bare cells (155). She spent forty years getting them hospitals. THOSE HOSPITALS WERE CLOSED, AND THE POPULATION RETURNED TO THE JAILS. The measurable outcome of the whole two-century project is that there are now roughly ten times as many severely mentally ill people in American correctional facilities as in psychiatric hospitals.
THE ARGUMENT IS NOT THAT THE ASYLUMS SHOULD HAVE BEEN KEPT. Read 153, 158, 159 and 160 together and the case for closing them is overwhelming. THE ARGUMENT IS THAT CLOSING THEM WAS THE ONLY HALF OF THE PLAN ANYONE PAID FOR. Deinstitutionalisation is not a story about a bad idea. It is a story about a good idea that was implemented at exactly fifty per cent, and about which half a legislature will fund when the other half has no constituency.
KENNEDY'S SIGNATURE ON THE 1963 ACT IS THE DETAIL THAT BINDS THIS ERA TOGETHER. His sister ROSEMARY had been lobotomised at twenty-three, on their father's arrangement, and institutionalised for life (158). The man who set out to empty the asylums had watched what they were for.
Its timeline
- 1954 CHLORPROMAZINE, sold as THORAZINE, is approved in the United States. For the first time psychosis can be suppressed pharmacologically, and discharge becomes conceivable at scale.
- 1955 The resident population of American public psychiatric hospitals peaks at roughly 560,000.
- 31 OCTOBER 1963 KENNEDY SIGNS THE COMMUNITY MENTAL HEALTH ACT, funding a national network of community centres to replace the asylums. He is assassinated three weeks later. ONLY HALF OF THE PROPOSED CENTRES ARE EVER BUILT, NONE IS FULLY FUNDED, AND THE ACT PROVIDES NO MONEY TO RUN THEM LONG-TERM.
- 2 SEPTEMBER 1967 GOVERNOR RONALD REAGAN signs California's LANTERMAN-PETRIS-SHORT ACT, in force from 1969: no one may be held against their will for more than 72 hours without a hearing, and the counties take over care with no obligation to provide it. Other states follow. The legal grounds for holding people disappear at the same time as the funding for treating them.
- 1970s–90s State hospitals close across the country. THE PROMISED COMMUNITY SYSTEM DOES NOT ARRIVE, and the discharged population appears instead in single-room occupancy hotels, on the street, and in county jails.
- 2014 TRANSINSTITUTIONALISATION IS MEASURABLE. An estimated 383,000 people with severe mental illness are incarcerated — roughly TEN TIMES the number remaining in state psychiatric hospitals. Around 20 per cent of jail inmates and 15 per cent of state prison inmates have a serious mental illness.
- Present The debate has reopened in several jurisdictions over whether involuntary treatment should be easier to obtain, which is the argument of 1841 (155) being had again from the opposite direction.