The Discovery of the Mental Institution – With Apologies to David J. Rothman

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On February 15, 2018, President Donald Trump spoke about the shooting at Marjory Stoneman Douglas High School in Parkland, Florida, in which Nikolas Cruz killed seventeen people. While Trump did mention “a shooter,” who “opened fire on defenseless students and teachers,” when it came to solutions, he focused on mental illness rather than the tools that the shooter used to carry out mass murder. He stated, “We are committed to working with state and local leaders to help secure our schools, and tackle the difficult issue of mental health.” A week later, at a White House listening session with state and local officials, Trump did suggest that stronger background checks for gun purchases would be on the table¹, but he also reiterated the mental health theme, saying that his administration was “talking seriously about opening mental institutions and in some cases reopening” them.²

It is true that mental illness can contribute to violent behavior. Some of the past decade’s mass shooters have had diagnoses of mental illness. Adam Lanza, who shot and killed his mother and then 26 people at Sandy Hook Elementary school, had received psychiatric attention. Seung-Hui Cho, who killed 32 people at Virginia Tech, also had received a psychiatric evaluation. However, a February 2018 New York Times article by Benedict Carey references Dr. Michael Stone, a forensic psychiatrist at Columbia University who has studied mass killers. Stone emphasized: “Most of these shooters are angry, antisocial individuals you cannot spot in advance.”

Stone’s frightening assertion aside, effective medical care for the mentally ill could help. But unfortunately, the largest care facilities for the mentally ill in our country currently are jails and prisons.³ Although prisons are required to provide treatment for the mentally and physically ill, they fall far short. Studies of mental health care in prisons detail the horrors faced by those with mental illness. Instead of receiving humane treatment, mentally-ill prisoners are often kept in solitary confinement and over medicated, their crises met with force rather than compassion.⁴

Even when those suffering from serious mental illness can secure a bed in a state psychiatric hospital, conditions are often no better. In 2015, Leonora LaPeter Anton, Michael Braga, and Anthony Cormier published a series of articles in the Tampa Bay Times and the Sarasota Herald-Tribune titled “Insane. Invisible. In Danger.” These journalists investigated the conditions in Florida’s state-funded mental hospitals and found that “years of neglect and $100 million in budget cuts have turned” the hospitals “into treacherous warehouses where violence is out of control and patients can’t get the care they need.”

There is good psychiatric health care in this country, and many health-care providers in state-funded institutions provide care to the best of their abilities, but in a society that emphasizes individual rather than collective solutions and where healthcare is seriously underfunded, good care is mostly reserved for the wealthy. The best psychiatric hospitals are private pay and cost approximately $35,000 per month.⁵ In our country, everything, even psychiatric care, is marketed, commodified, and out of reach of ordinary working Americans.

The problems of care for the mentally ill are not new, of course. Mental health care has never been adequate in this country. Incidents of violence by the mentally ill have always sparked calls for reform. For a return to the asylum to work, our nation needs to pay attention to that history. If we are going to take seriously the logic that opening mental health institutions (and not controlling firearms) is the solution, it would be useful to know that history and to see the ways treatment for violent offenders who are also mentally ill has fallen short.

In 1805, a New Hampshire newspaper, the Farmer’s Mechanic, reported on a double murder in Hollis, New Hampshire. The author of the article noted that John Peneuil Kendrick, the perpetrator, had exhibited signs of insanity for years, but when sane, was a good citizen. On the day in question, Kendrick’s insanity got the better of him and he murdered his mother and sister. In light of this, the editors wrote that this tragedy was “a solemn warning against allowing insane distracted persons the privilege of doing mischief, by permitting them to go at liberty. We think it worthy of legislative attention.”⁶ However, legislative attention has always been hard to come by in the United States. Historically, legislatures have leaned toward punishment rather than care, a trend that continues in our current era.

For historians, it is not surprising that jails and prisons are currently the largest providers of mental health care in this country. As long as the United States has been a country, state governments have been using jail or prison as a solution to the potential for violent acts committed by the mentally ill. In 1798, Massachusetts passed a regulatory act that read as follows: “That when it shall be made to appear to any two justices … that any person … is lunatick and so furiously mad as to render it dangerous to the peace or the safety of the good people for such lunatick person to go at large; the said justices shall have full power … to commit such person to the house of correction.”⁷

The stress was on providing incarceration rather than mental health care. As legislators encountered the mentally ill and saw the ways such men and women could disrupt the workings of society, they responded with legal attempts to remove those disruptions. Care for the mentally ill figured into the equation but was secondary to protecting the community and working toward order and stability.

Reformers, of course, had other ideas. The eighteenth-century hospital movement and the nineteenth-century asylum movement were well-intentioned movements to provide quality care for the mentally ill. The Pennsylvania Hospital opened in 1751 with a mission to restore “the distempered poor” to “health and comfort,” so that they could “become useful to themselves, their families, and the publick.” The Virginia legislature funded a small hospital for the care of the mentally ill in 1773. A century later, every state had at least one publicly-funded hospital for the treatment of the mentally ill.

While reformers had success in getting asylums and hospitals built, they had less success when it came to quality care in those institutions. By the 1950s, a new generation of reformers began to argue for deinstitutionalization, shining a light on the abuses in many of the mental hospitals that had been endemic for a century or more. By the 1960s, the federal government had passed laws to transfer the care of the mentally ill from long-term residency in mental health hospitals to community mental health centers.

In 1980, President Jimmy Carter signed the Mental Health Systems Act into law, which continued funding for federal community health centers. One of President Ronald Reagan’s first acts in 1981 was to repeal that act, signing the Omnibus Budget Reconciliation Act. As a result, people with serious mental illnesses were removed from institutions, many of them moving to the streets for lack of an alternative and living in dangerous, unhealthy conditions.

The history of mental health care and the abuses within the institutions created to address mental health issues, of course, is what all lawmakers should be paying attention to, but what few or none of them will. In a 2015 article, Dominic Sisti, Andrea Segal, and Ezekiel Emanuel called Americans to return to the building of asylums, but cautioned “Asylums are a necessary but not sufficient component of a reformed spectrum of psychiatric services.” They use the Worcester Recovery Center and Hospital as an example, a center that cost $300 million to build and which has a $60 million annual budget.⁸

For any proposed asylum to work properly, it would need both funding and regulated quality care. In a political climate controlled by regulation-averse Republicans who campaigned on the end to Medicaid expansion, it is likely that visitors to Trump-era asylums would echo the 1796 French visitor to the Virginia Eastern Asylum who found that “the unfortunate maniacs are rather abandoned to their wretched state.”⁹

We have much to learn from our history, of course. We should call on the good intentions of the past reformers to create places that would treat those with mental illness using the best practices available. We should also call on our memory of the failures of even the best-intentioned facilities and make sure that any new asylums are properly funded and under strict oversight. Like the anonymous writers in the 1805 Farmer’s Mechanic, I think we should, among other things, turn legislative attention to the problems of violent and mentally ill offenders, but we should work toward care rather than punishment.

Further Reading

David J. Rothman, The Discovery of the Asylum: Social Order and Disorder in the New Republic (Boston: Little, Brown, and Company, 1971).

Notes

1. Ironically, and horrifically, the brief (and then later tabled) call for stronger background checks came just a few days shy of the one-year anniversary of Trump signing a bill that rolled back a regulation that made it harder for people with mental illnesses to purchase a gun. Return to text.
2. Mental illness is part of the human condition, but the United States outpaces every country and region in mass shootings. Adam Lankford, “Public Mass Shooters and Firearms: A Cross-National Study of 171 Countries,” Violence and Victims 31 (2016), 192. Return to text.
3. Dominic A. Sisti, Andrea G. Segal, and Ezekial J. Emanuel, “Improving Long-term Psychiatric Care: Bring Back the Asylum,” JAMA 313 (January 20, 2015), 243. Return to text.
4. Terry A. Kupers, “A Community Health Model in Corrections,” Stanford Law & Policy Review 26 (2015): 119-158. Return to text.
5. As reported in Cathy Cassata, “Is President Trump Right? Should We Open More Mental Institutions?” HealthLine, March 6, 2018. Return to text.
6. Homicide among Adults in New Hampshire and Vermont, 1775-1900, compiled by Randolph Roth, 200 version, accessed July 24, 2015. Return to text.
7. “An Act in Addition to an Act entitled ‘An Act of Suppressing Rogues, Vagabonds, Common Beggars and Other Idle, Disorderly and Lewd Persons,” quoted in Henry M. Hurd, ed., The Institutional Care of the Insane in the United States and Canada, vol. 2 (New York: Arno Press, 1973), 584. Return to text.
8. Sisti, et al, “Bring Back the Asylum,” 244. Return to text.
9. Quoted in Gerald N. Grob, The Mad Among Us: A History of the Care of America’s Mentally Ill (New York: The Free Press, 1994), 21. Return to text.

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Featured image caption: Sheppard Asylum, rear elevation, Baltimore, MD. (Courtesy National Library of Medicine/Flickr Commons)