In the wake of the Florida shooting, a growing number of elected officials, including President Donald Trump, have made the curious decision to blame people with mental illness for gun violence, rather than guns. In a country whose leaders are unwilling to confront a powerful gun lobby, mental health makes an easier scapegoat.
“Years ago, we had mental hospitals, mental institutions, we had a lot of them and a lot of them have closed. Some people thought it was a stigma. … Legislators thought it was too expensive,” said the president in remarks at his “listening session” last Wednesday with shooting survivors. “Today, if you catch somebody, they don’t know what to do with them. He hasn’t committed the crime, but he may very well and there’s no mental institution, there’s no place to bring them. And we have that a lot.”
Trump reiterated his push to expand institutionalization yesterday at a meeting with the nation’s governors, making it a central part of his administration’s response to mass shootings. These comments echo a similar call from the Broward County sheriff, who proposed expanding the Baker Act, Florida’s involuntary commitment law, to make it easier to institutionalize people on the basis of social media postings.
The president labors under a common misconception, increasingly popular within conservative circles. The myth goes like this: Prior to de-institutionalization, people with mental illness were treated fairly and humanely in clean, well-run facilities that were shut down only due to cost-cutting directives from state legislatures and the ill-conceived notions of a few overly zealous advocates. Today, proponents of this worldview argue, the mentally ill have more rights than are good for them. Those rights supposedly make it impossible to commit people we know to be dangerous before they harm themselves or others.
That story misrepresents the current system, and it obscures an ugly history. While institutionalizing people with mental illness is no longer as simple as it once was, our system still allows for involuntary commitment—but only if there are sufficient grounds for believing those individuals truly are a danger to themselves or others.
This was not always so. Early American standards for institutionalization were lax. In much of the country, an order from a public official or police officer could suffice. In some cases, far less was required—Benjamin Rush, the preeminent physician of the Revolutionary era, once institutionalized a man simply by writing, “James Sproul is a proper patient for the Pennsylvania Hospital” on a scrap of paper.
By the 1840s, courts were beginning to review institutional placement, but still provided broad deference to petitioners attesting to the incapacity of those they sought to commit. In one early case, a 67-year-old widower named Josiah Oakes was institutionalized for four years after attempting to marry a younger woman his children disapproved of.
Or consider the case of Elizabeth Packard, whose husband, Theophilius, a Calvinist minister, had her committed because of her disagreement with the doctrines of her church on original sin and other matters. After she dared to disagree with him in front of his congregation, Theophilius had her dragged from her bed and committed to the Insane Asylum in Jacksonville, Illinois.
At the time, state law allowed for a husband to commit his wife with the approval of only the institution’s superintendent. It took Elizabeth Packard four years to secure her release, during which time her husband left the state with her children. Packard would later become a lobbyist for the rights of both married women and institutionalized persons.
These cases reflected the historical lack of protections against involuntary confinement. From the medieval period onward, commitment to a mental hospital could frequently be traced to inheritance disputes, where heirs sought to limit the ability of aging relatives to disinherit, marry, or even spend their own money. Similarly, family arguments over religion, ideology, or child-rearing might end in hospitalization.
Institutionalization in the 19th century was rooted largely in the doctrine of parens patriae, which authorized the state to intervene on behalf of individuals deemed incapable of acting in their own best interests. Because it was “for their own good,” few procedural protections were deemed necessary.
Reformers like Dorothea Dix sought to establish mental institutions to offer relief to “the insane,” who were frequently chained or locked up in basements or poorhouses. Dix toured the country, proposing reforms to improve the quality of care received by Americans struggling with mental illness. Her efforts contributed to vast improvements in material conditions. Many still associate institutionalization with this benevolent spirit, but a closer examination of history suggests otherwise.
Although Dix’s efforts may have jumpstarted American institutionalization, it was a far darker set of impulses that brought it to scale. Dix died in 1887—the closest census, 1890, reports an institutional population of 74,028 (118.2 people per 100,000 population). By 1910, that number had jumped to 187,791 (204.2 per 100,000) and by 1940, to 591,385 (585 per 100,000). What was responsible for such a rapid rise in the population of America’s mental institutions?
One key factor was the rise of eugenics. For most of the first half of the 20th century, elites on all sides of the political spectrum sought to blame all of America’s social ills on the presence of inherited mental disability in the population. In newspapers, magazines, popular cinema, and even preachers’ pulpits, eugenicists called on America to combat the scourge of “bad blood.” Eugenicists preached a policy of involuntary sterilization, immigration restrictions, and mass institutionalization, promising relief of crime, prostitution, and even labor unrest.
Eugenicists were responsible for vast changes in social policy, disproportionately targeting minorities and low-income Americans with and without disabilities. At the height of the institutional project, three in every 1,000 Americans were institutionalized.
The Second World War rendered eugenics disreputable because of its association with Nazi Germany, and during the postwar era new ideas about civil rights began to affect health care (including, for example, new requirements for patients’ informed consent to medical treatment).
By the 1960s, states had begun to shift the criteria for involuntary commitment, stipulating that individuals must be a danger to themselves or others before they could be committed.
The courts have ruled that such determinations must be on the basis of clear and convincing evidence. This is well below the “beyond a reasonable doubt” standard used in criminal cases, but a significant improvement over lax criteria used in the early 20th century.
As the rationale behind institutionalization shifted, so too did the reliance on hospitals as the only method of treatment. A series of exposés of conditions in state institutions led to greater scrutiny. Americans began to question the wisdom of segregation and restraint as tools to promote mental health. A growing body of evidence showed that congregating people in isolated buildings reduced their quality of life and precluded the community connections that were often so valuable for recovery.
In 1963, Congress passed the Community Mental Health Centers Act to help build a system of community-based supports to assist those leaving mental hospitals. From 1977 to 1980, the Carter administration led a concerted effort to improve and expand community services, leading to the Mental Health Systems Act of 1980. Unfortunately, less than a year after President Carter signed the bill into law, the Reagan administration made the program part of a block grant for mental health funding to the states and reduced the budget by 75 percent to 80 percent of what states would have otherwise received.
When Broward County’s sheriff complains that state involuntary confinement laws require that “you have to have a reason, you have to be able to articulate that they’re a threat to themselves or a threat to someone else,” he is bemoaning the presence of crucial protections hard-won after years of advocacy.
Some now argue that we should turn back the clock, abandoning important civil liberties in favor of a streamlined pathway into institutional care. Some, like Trump, justify that claim in the name of public safety. The evidence is against such arguments.
A comprehensive analysis from the Bazelon Center for Mental Health Law finds no correlation between the availability of psychiatric hospital beds and either murders involving firearms or incarceration rates. Research has found that serious mental illness accounts for only between 3 percent to 5.3 percent of violent crime—and even this association is reduced after controlling for neighborhood and substance abuse problems.
Even when perpetrators have some history of mental instability, their actions are typically motivated by exposure to extreme ideologies that glorify violence. Our culture needs to come to grips with a truth we lost long ago: Horrifying acts are sometimes the result of evil ideas, not illness.
Others believe that the decline of quick and easy institutionalization has made it more difficult for people with mental illness to access care. That explanation ignores an obvious reality: Most people who forgo mental health treatment do so for the same reason too many Americans forgo other kinds of health care: They can’t afford it.
Involuntary commitment doesn’t make care affordable; it only satisfies a demand for coercion that is all too common among legislators who refuse to fund help for people who actively desire it. This is the problem with making mental health policy only after a mass shooting. Doing so ill-serves people with mental illness–-along with the millions of Americans calling out for real solutions to the problem of gun violence.