Why were mental hospitals closed in the United States?
Mental hospitals in the United States were closed primarily due to a combination of social, political, and economic factors that fueled the deinstitutionalization movement starting in the 1950s.
Background and Initial Impetus
The process of deinstitutionalization, which involved replacing long-stay psychiatric hospitals with community-based mental health services, emerged from a complex interplay of forces. During and after World War II, public awareness of the dire conditions in mental institutions grew significantly. Conscientious objectors assigned to work in understaffed mental hospitals exposed the neglect and abuse prevalent in these facilities, with a notable 1946 exposé in Life magazine amplifying public concern[1]. This led to increased advocacy for reform, including the establishment of the National Mental Health Foundation by these objectors, which later merged into broader mental health advocacy groups[1]. Additionally, the high rejection rate of military recruits due to neurological or psychiatric issues during the war highlighted the prevalence of mental illness and its societal costs, prompting further calls for improved mental health services and research through initiatives like the National Mental Health Act of 1946[1].
Key Drivers of Deinstitutionalization
Several critical factors drove the closure of mental hospitals. The introduction of psychotropic drugs in the 1950s, such as chlorpromazine (Thorazine), offered a new treatment paradigm that appeared to manage severe symptoms effectively, suggesting that patients could live outside institutions with medication[1][3]. This pharmaceutical advancement coincided with a shift in professional and humanitarian perspectives that favored community-based care over institutional confinement, a view that gained traction alongside the Civil Rights Movement’s emphasis on individual liberties[1]. President John F. Kennedy’s support was pivotal; his 1963 Mental Retardation Facilities and Community Health Centers Construction Act aimed to replace custodial institutions with community centers, though the envisioned network of centers largely failed to materialize[3]. Additionally, the 1965 creation of Medicaid accelerated this shift by restricting federal funding for inpatient psychiatric care, incentivizing states to move patients out of costly facilities[3].
Economic considerations also played a significant role. States sought to reduce the financial burden of maintaining large mental institutions, and deinstitutionalization was seen as a cost-effective alternative, especially as public opinion turned against the inhumane conditions documented in facilities like Willowbrook State School, where a 1972 television broadcast revealed shocking abuses[1][2]. Legal rulings further supported this movement; for instance, the 1973 Souder v. Brennan decision mandated that patients in institutions be paid minimum wage for labor, effectively outlawing institutional peonage and increasing operational costs, while experiments like Rosenhan’s in 1973 underscored the need for reform by exposing diagnostic and treatment flaws in mental hospitals[1].
Public Discourse and Controversies
Public discourse around deinstitutionalization has been marked by both optimism and criticism. Initially, there was widespread support for the movement as a humane alternative to the often brutal conditions of state hospitals, driven by exposés and advocacy that framed institutionalization as a violation of civil rights[1][2]. The Lanterman-Petris-Short Act of 1967 in California, signed by Governor Ronald Reagan, epitomized this shift by severely limiting involuntary institutionalization, reflecting a broader national trend influenced by civil liberties concerns and Supreme Court rulings[2]. However, as deinstitutionalization progressed, the lack of adequate community mental health infrastructure became apparent. Critics argue that the promised community centers were underfunded and insufficient, leaving many former patients without proper care, often resulting in homelessness or incarceration[2][3]. This has led to a narrative, often repeated in media, that deinstitutionalization directly caused a rise in mentally ill individuals within the criminal justice system—a theory rooted in the Penrose hypothesis of the 1930s, which posits an inverse relationship between asylum and prison populations, though scholars now view this as an oversimplification[3].
Contemporary discourse reflects ongoing tension. Some, like Vern Pierson in his commentary for CalMatters, link deinstitutionalization to increased homelessness and untreated mental illness, viewing it as a well-intentioned but poorly executed policy that, combined with later prison reforms under Governor Jerry Brown, exacerbated social issues[2]. Others, as discussed in The Atlantic, challenge the simplistic blame on deinstitutionalization for the mental health crisis in jails and prisons, pointing to broader systemic failures in mental health care funding and policy, including Medicaid’s limitations and the inadequacy of community-based alternatives[3]. Public opinion remains divided between those who see deinstitutionalization as a necessary rejection of past abuses and those who believe it abandoned vulnerable populations to the streets or incarceration, with fatal police encounters and high suicide rates in jails cited as evidence of a new crisis[3].
Consequences and Current Challenges
The closure of mental hospitals reduced the asylum population from over half a million in 1955 to just over 100,000 by the mid-1980s, with numbers continuing to decline[3]. However, the transition to community care has been incomplete; many individuals with mental illness now find themselves in jails or prisons, where nearly half of inmates have a diagnosed mental illness compared to about a fifth in the general population[3]. This shift has placed law enforcement in the role of de facto mental health responders, often without adequate training, leading to tragic outcomes[3]. The public continues to grapple with balancing civil liberties against the need for care, as laws protecting against forced treatment make hospitalization difficult while arrest remains an easier option[3].
Sources
- [1] https://en.wikipedia.org/wiki/Deinstitutionalization_in_the_United_States - This source provides a comprehensive overview of the deinstitutionalization process, detailing historical context, key factors like drug therapy and policy changes, and public criticisms of mental hospital conditions.
- [2] https://calmatters.org/commentary/2019/03/hard-truths-about-deinstitutionalization-then-and-now/ - Vern Pierson critiques deinstitutionalization as a contributor to homelessness and untreated mental illness, linking it to broader policy failures in California under Reagan and Brown.
- [3] https://www.theatlantic.com/health/archive/2021/05/truth-about-deinstitutionalization/618986/ - Alisa Roth offers a nuanced perspective, challenging the direct causal link between deinstitutionalization and incarceration of the mentally ill, emphasizing systemic failures in community care and funding.