The Rehabilitation of the Asylum

In the history of American mental hospitals and prisons, the 1960s appeared to represent an important departure. The reformers of the sixties, unlike their predecessors, were determined not so much to improve institutions as to devise alternatives. Just as asylums and prisons had grown up together in the 1830s and undergone parallel changes in the early 1900s, so it seemed they would both now lose their centrality as institutions of care and correction, to be replaced by community-based programs. The promise appeared so great and the goal so attainable that I thought it altogether appropriate in 1972 to publish an article titled "On Prisons, Asylums, and other Decaying Institutions."

Two decades later this formulation turns out to have been only partially correct. The mental hospital has decayed, in some places quite literally. Walking around the grounds of the state hospital in Northampton, Massachusetts is like visiting a ghost town: the once imposing red brick buildings stand empty, the unkempt grass grows up through cracks in the walkways, and the silence is eerie. But for the first time, public policies toward mental hospitals and prisons have not moved in tandem. In recent decades, as the number of patients in mental hospitals declined, the number of prison cells and prisoners swelled. In New York, for example, Democratic Governor Mario Cuomo has presided over the largest expansion of prisons in the history of the state. (Say what you will, Nelson Rockefeller presided over the largest growth of the state university system.) The United States, in fact, now leads the world in percentage of population under confinement; our ratio of 340 per 100,000 outdistances even South Africa and the Soviet Union.

The rise of the prison has received considerably less media attention and policy analysis than has the decline of the mental hospital. Perhaps there is a reluctance to explore a phenomenon that puts us in a harsher light than South Africa. And perhaps the answer seems too obvious: the burgeoning prison population reflects a war on drugs whose futility is matched only by its ferocity. Most likely, however, the relative inattention reflects the fact that except for a few dissenting voices, prison expansion has not been especially controversial. The fear of crime gives prisons legitimacy. Whether or not they deter or rehabilitate, they at least incapacitate offenders, and were public opinion the sole guide of public policy, offenders would be serving even longer sentences.

By contrast, the decline of the mental hospital is intensely controversial. Witness the frequency of newspaper and television coverage. The process of change has its own name, deinstitutionalization; it appears to have a common outcome, homelessness; and a number of recognizable victims, including Sylvia Frumkin (courtesy of Susan Sheehan's book, Is There No Place on Earth for Me?) and "Billy Boggs" (courtesy of former New York City Mayor Edward Koch and the New York Civil Liberties Union).

Only by appreciating how contentious deinstitutionalization is can one understand the unbridled anger and prosecutorial style that characterize Rael Jean Isaac and Virginia C. Armat's Madness in the Streets. In their hands, the policy represents all that was misguided and detrimental about the movements and ideas "fashionable in the 1960s." Deinstitutionalization, they insist, was in the first instance an attack on the core values of American society. It was spawned by those "on the political left, which used the mentally ill as catspaws in their struggle against middle-class culture." Worse yet, deinstitutionalization challenged the equity of the existing distribution of wealth and power; advocates used the mentally ill as evidence of "an unjust economic and political system," and linked their maltreatment to "such 'root causes' as low welfare payments." Isaac and Armat set out to rebut these contentions by blaming the left-leaning activists for the present predicament of the homeless mentally ill. Madness in the streets becomes the mirror that reflects the madness that swept through the academy and the courts (and hence such chapter and section titles as "The Academy Joins Anti-Psychiatry" and "The Law Becomes Deranged"). The plight of the mentally ill becomes a metaphor for the ills all of us would suffer if the legacy of the 1960s extended its cultural and political authority.

In the interests of full disclosure, I should note that Isaac and Armat include me in their indictment on the grounds that my book The Discovery of the Asylum, which deals with the origins of confinement in early nineteenth-century America, did not give sufficient weight to the benevolence of the founders of the mental hospital. Moreover, I have served for many years on the board of the Mental Health Law Project and did a stint on the board of the New York Civil Liberties Union, the two organizations that Isaac and Armat most vehemently denounce for their role in the deinstitutionalization movement. That deinstitutionalization has generally failed to deliver appropriate services to ex-mental patients or other persons in need of them is hardly debatable. Not I, nor anyone I know who was or is active in the movement, take pride in the fact that people have been neglected and abused both on the streets and in proprietary adult boarding homes. The question is why the outcome of deinstitutionalization should have been so grim, and what should be done to remedy the situation.

On this question, Madness in the Streets is longer on invective than insight. The authors parade a roster of villains through their pages, castigating each one in turn for depriving the mentally ill of the institutions and procedures that would have served them well. In the front ranks are the ideologues of the counterculture, R. D. Laing, for celebrating madness, and Thomas Szasz, for denying its reality. Close behind come academics such as the sociologist Erving Goffman, for undercutting the legitimacy of the mental hospital. What Isaac and Armat offer are caricatures of ideas in order to denounce them. They accuse Goffman of arguing that mental hospitals cause mental illness, when actually he maintained that mental hospitals promote and reinforce the types of behavior that are maladaptive in the outside society. Another target of theirs is David Rosenhan, a social psychologist who sent informants into mental hospitals and learned that staff psychiatrists and nurses could not differentiate them from genuinely ill patients. Isaac and Armat fault Rosenhan for not sending informants feigning heart disease or muscular dystrophy to general hospitals; in their view, the medical staff would also have made errors in diagnosis. But even if this unsubstantiated and unlikely hypothesis proved correct, its relevance is unclear, as we do not involuntarily commit persons with shortness of breath or poor muscle control to hospitals.

Although Isaac and Armat have some harsh words for psychiatrists -- mostly for being too passive and pusillanimous before the onslaught -- the primary villains of their story are the public interest lawyers who have defended the rights of the mentally ill, particularly the lawyers who have sought stricter civil commitment laws. They are responsible, according to Isaac and Armat, for the accelerated trend to deinstitutionalization in the 1970s. While the authors acknowledge the role of psychotropic drugs like thorazine in bringing about a decline in institutionalization during the 1960s, they argue that the process got out of hand during the 1970s as a result of lawsuits on behalf of patients' right to treatment and their right to refuse treatment. These suits ostensibly made it impossible to admit, hold, and cure the mentally ill, thereby producing the disaster of deinstitutionalization.

To sustain so single-minded an attack, Isaac and Armat must underplay or ignore a host of considerations, starting with the dismal state of mental hospitals through the first half of the twentieth century. Throw-away lines admit that the facilities represented what the journalist and historian Albert Deutsch called, in a 1949 book, the "shame of the states." But nowhere do the authors consider the implications of the persistent pattern of appalling conditions; for to do so would undercut their own favorite prescriptions. If the institutions have been shameful, it was (and continues to be) appropriate to limit the reach of involuntary commitment. Moreover, were Isaac and Armat to acknowledge the grievous problems of mental hospitals, they would have to acknowledge the contribution of the mental health bar. Attorneys from the Mental Health Law Project and the New York Civil Liberties Union, not the leadership of the American Psychiatric Association or hospital superintendents, exposed the nightmarish conditions in institutions such as Bryce State Hospital in Alabama and Saint Elizabeth's in Washington, D.C. Discovering that mental patients were confined to 5,000- or 10,000-bed facilities with only one or two staff psychiatrists, the lawyers initiated and often won class-action suits to transfer residents to less restrictive alternatives.

Indeed, to reckon fully with asylum conditions is to recognize that deinstitutionalization has made visible degradations that were once invisible. The back wards and back alleys both abuse the mentally ill, but most Americans never saw life in the back wards, and those of us who live in big cities cannot avoid encountering ex-mental patients on our streets.

To justify their claim that the law abandoned the mentally ill, Isaac and Armat exaggerate the therapeutic effectiveness and minimize the harmful side-effects of psychiatric interventions, including not only psychotropic drugs but electroconvulsive therapy (ECT). Some studies do suggest that ECT is effective in treating the acutely depressed. But to make ECT relevant to their case, Isaac and Armat must do more than defend its use in acute depression, for such patients do not end up in back wards. They have to advance the claim that the bias against ECT has prevented its use in chronic schizophrenia where, they assert, it would be effective. This proposition, however, is not based on peer-reviewed and published findings; rather, they cite personal interviews with two English "experts" on ECT to buttress the claim. Nowhere do they state frankly that the prevailing opinion among leading researchers and practitioners, including those who otherwise endorse the use of ECT, is that it has almost no efficacy in chronic schizophrenia: perhaps one in ten or twenty patients will show improvement. We might debate whether a one-in-ten or one-in-twenty chance is a gamble worth taking as against long-term illness, and whether such odds would justify the administration of ECT over a patient's refusal. But that complexity of analysis is not to be found here. Instead, speculation and innuendo suggest that a miracle cure is being repressed.

Yet are Isaac and Armat right in casting the mental health lawyers as the major agents of social change, whatever one thinks of their policies? Was deinstitutionalization fashioned in the courtroom? Is the core of the problem the derangement of the law? I think not.

Here I must return to my opening observation that in the 1970s the fate of prisons and mental hospitals diverged. Mental health lawyers had their precise counterparts in prisoners' rights lawyers. In both areas, lawsuits charged substandard conditions and unconstitutional practices. Academicians criticized prisons no less sharply than mental hospitals (Goffman's writings are an apt case in point). Prisoners' rights litigation actually preceded and helped to inspire mental health litigation. Since conditions in state hospitals were often worse than in state prisons, it was inevitable that litigators would ask why so many people were deprived of their liberty and subject to such abuse when they were not guilty of anything.

But if it was all a lawyers' plot or the derangement of the law, prisons and mental hospitals should have been equally affected. Yet they were not. To understand the distinctive history of the deinstitutionalization of the mentally ill requires a far broader analysis than Isaac and Armat's bill of indictment against lawyers, academics, and the courts.

Not all of that analysis appears in Ann Braden Johnson's Out of Bedlam, but she does skillfully examine two considerations -- politics and money -- that are, remarkably enough, almost completely missing from Isaac and Armat's account. Johnson takes us out of the academy and courtroom and into the legislatures and executive departments that have framed and carried out much of the deinstitutionalization policy. Although one might have thought some of this material was already well known, Isaac and Armat demonstrate just how necessary it was for Johnson to write her book.

She starts with the fact that in the period after World War n, hospital-based custodial care was extremely expensive and growing in cost far more rapidly than inflation. Over the period from 1939 to 1949, the Consumer Price Index rose 71 percent, but capital expenditures for state hospitals increased by 432 percent, and maintenance costs by 201 percent. Patients were living longer (courtesy of medical advances) and were not being discharged, forcing states to provide more beds and make more outlays, even without being particularly generous. Appropriations for mental hospitals were far lower than for general hospitals, and public mental hospital spending lagged well behind private facilities. In fact, in the late 1940s, the American Psychiatric Association calculated that to satisfy its standards for care, states would have to increase their spending by another two and a half times.

Facing severe fiscal pressures, states might have adopted deinstitutionalization on their own, but federal policy soon intervened to provide a powerful impetus. With the 1965 passage of Medicare and Medicaid, the federal government assumed between half and three-quarters of the cost of nursing home care for the elderly, thereby giving the states every incentive to discharge aged inpatients (some 30 percent of the total) to nursing homes. Then, in 1972, Congress enacted Supplemental Social Security Income (SSI), providing the disabled with a monthly stipend, with no requirement that the states match the funds, or cover the cost of administration, or, most important, provide ancillary programs. The impact of SSI on mental hospitals was direct and immediate. "In 1974," Johnson notes, "the first year SSI was available, state hospitals saw a nationwide decrease in population of 13.3 percent, the largest decrease ever." In other words, state budget officials, not mental health lawyers, were the pied pipers leading patients out of the hospital.

In the design of federal programs Johnson finds a powerful reason why discharged mental patients went without services in the community. No one built residences for them in the community because the regulations did not require anyone to do so. Housing the ex-patients was left to the marketplace, and so adult boarding homes proliferated. There were other reasons as well. The community mental health clinics established in the Kennedy administration were supposed to serve as the alternatives to state hospitals, but in keeping with an outlook that characterizes much of American medicine, the clinics devoted themselves to acute rather than chronic patients. It was the worried well from the middle class, not the one-time back-ward patient from the dependent class, that captured their concern. Most disastrously, state dollars appropriated for mental hospital care did not follow (and to this day do not follow) patients into the community. Even as inpatient populations declined, funds for the facilities held steady or even increased, and for an obvious reason: employee unions mounted awesome and effective lobbying campaigns to protect their jobs. New York, which spends more money per capita than any other state on mental health, still devotes 70 percent of its dollars to the institutions, although 70 percent of the mentally ill are in the community.

Looking back, the dynamics that undercut the delivery of community services were neither obscure nor overly complex. Nevertheless, advocates were slow to grasp them and, more significant, not able to reverse them. They won their cases in the courtroom, not in the legislature, and were far more adept at fashioning constitutional arguments than in building political constituencies. Recognizing some of the influence exerted by the unions, they were ill-equipped to marshal competing political support. So, too, convinced that deinstitutionalization would not cost more than existing systems of care, and might even cost less, they were unprepared for the depth of executive and legislative resistance to new expenditures. And as newcomers to the field of mental health, they failed to appreciate how powerful the bias against chronic care is in psychiatry and medicine. They assumed that a patient is a patient, or at least a paying patient is a patient, until the experience of community mental health centers showed otherwise. Whatever the past lapses, the critical question is where we go from here. To Isaac and Armat the answer is straightforward: reintroduce compulsion into the field of mental health, shift the balance of power from lawyers, where it has had "calamitous" results, to psychiatrists. "Existing treatments," they tell us, "need to be used more aggressively and intelligently." The standard for involuntary commitment and treatment should be a "need for treatment," not dangerousness to self or to others. Provisions must be made for long-term hospitalization and some type of outpatient commitment, so that the mentally ill can be compelled to take their medications. ECT should become the intervention of choice for first acute psychotic episodes, for "there is evidence that... it may be the most effective of all available treatments."

The essential characteristic of this list is its presumption that we have all the technologies and skills, both medical and administrative, to solve the problem of chronic mental illness. The interventions are at hand, the institutions are standing empty, and hence all we need to do is rediscover the asylum and the problems will be solved. Apparently, none of this will cost anything in fiscal or political terms, and hence Isaac and Armat find it unnecessary to analyze either state budgets or state bureaucracies. They do not pause to consider whether conditions in revived state hospitals might again degenerate or whether in the design of programs, compulsion may substitute for quality.

The temptation to redraft mental health laws in the name of rescuing the deinstitutionalized from the misery of the streets is so strong that even analysts far more sophisticated than Isaac and Armat succumb to it. Peter Rossi is a case in point. His recent and impressive study, Down and Out in America, better than any other work I know, clarifies what is old and what is new about the phenomenon of homelessness. Using the many earlier sociological studies of skid rows and hobos as a bench mark, and comparing their findings with current survey data of the homeless, he demonstrates that those now on the street are far more likely to be young (ages twenty to thirty, not, as it used to be, between forty and fifty), members of minorities (50 to 75 percent black, not 70 percent white), and women (20 to 25 percent, not 1 or 2 percent). The fifty-year-old white male vagrant who once slept in a flophouse on skid row has given way to a thirty-year-old black, male or female, sleeping on streets throughout the city.

Rossi also compares the homeless population with the domiciled destitute to see who among the poor end up on the street. He emphasizes the critical role of personal histories, particularly the impact of mental disability, alcoholism, and criminal records. The presence of these characteristics, for understandable reasons, prompts families and friends to sever ties with the individual, to refuse to share living space, thereby driving him, or her, into the streets.

Rossi addresses directly the question of the links among homelessness, mental disability, and deinstitutionalization. Given his method, he is able to demonstrate that the homeless have always included a significant number of mentally disabled persons, and it would be inappropriate to blame deinstitutionalization entirely for the problem. "That there are mentally ill persons among the homeless today may simply reflect continuity with the past." Rossi is alert to the timetable of deinstitutionalization, demonstrating that a process that reached its peak in the 1970s cannot be the root cause of homelessness in the 1990s. Finally, he is aware of the complexities of cause and effect, and how difficult it is to resolve whether mental illness led to homeless-ness or whether homelessness leads to mental illness.

These points notwithstanding, Rossi is deeply troubled about non-institutionalization, which he takes to be the result of the fact that "it has become considerably more difficult to commit people to a mental hospital without their consent." Earlier studies estimated that between 10 and 20 percent of skid row residents had mental disabilities; Rossi now calculates that 20 to 30 percent of the homeless have severe depression and "definite signs of psychotic thinking." Indeed, the percentage of mental disability among the homeless appears significantly higher than among the extremely poor who are domiciled.

Armed with these findings, Rossi offers several policy recommendations to combat homelessness. One is to get the homeless their due in welfare payments, for few of them receive public assistance or food stamp benefits for which they qualify. When it comes to the mentally disabled homeless, however, he takes a different tack, insisting on their need for "total-care institutions," including mental hospitals for "some of the most impaired." He notes that even though this proposal may seem a step backward to the civil libertarians, guarding someone's civil rights cannot mean leaving that person at "considerable physical risk." Thus, Rossi advocates expanding the number of mental hospital beds, discharging patients from them only when supportive living arrangements are available, and, like Isaac and Armat, recodifying involuntary commitment standards to make it easier to confine those who are acting "in a bizarre or aggressive manner, are incoherent, or are neglecting to care for themselves."

Rossi does not elaborate on these proposals, and fails to ask any of the tough, second-order questions. For someone alert to the historical dimension, he might at least have pondered whether the mental hospital is capable of delivering humane care, let alone total supportive care. Aware of budgetary limitations, surely he might have wondered about the source of funding for the mental hospitals, and what the trade-offs in support for other programs might be. He could have asked where the incentives and support to build alternate living arrangements would come from once the mentally disabled were recommitted -- from the hospitals that received their budgets on a per-patient basis? From the community that had no empathy for them? From the politicians who are happy to have a problem out of sight and out of mind? He might have also scrutinized his own criteria for commitment. What does it mean to say that a person is neglecting his own care when he lacks support from social service agencies or from family and friends, or when for good reason he considers shelters worse than prisons? Instead, we get once again the formulaic opposition between civil liberties and decent care. If only the issue were so straightforward -- if only the civil libertarians were the major barrier to caring for the homeless -- we would reach solutions in short order.

Ann Johnson, while reluctant to make recommendations, rejects a reliance on compulsion: "Forced incarceration, be it involuntary hospitalization or frank imprisonment, can in no way be conceived of as doing its victims a favor." And she does not want to abandon deinstitutionalization, which "was a great step forward and we are right to keep trying to make it work." But how are we to succeed in light of past failures? Johnson gives us overgeneral principles and directions, all important, but not adding up to a concrete agenda for action. Programs, she rightly informs us, should be designed to suit the clients, not, as is usually the case, to squeeze clients into existing services. But she immediately concedes the difficulty of achieving the change: 'The need to maximize revenue is what drives the system; and that is why it is naive, even if correct, to call for a return to public policy made on the basis of what patients need." She goes on to plead that we stop "wasting money on institutions" but does not address how advocates are to reverse the priorities. Finally, she thinks it essential to bridge the gap between those who do and those who plan, between those at the desk and those in the field. She is persuaded that "the mental health field has altogether too many people with too many ideas about fixing it and not enough people to do the actual work." But once again, there is no advice on how to realize the change.

Thus, while Isaac and Armat, and to a degree Rossi as well, give us proposals that are relatively easy to implement but may do more harm than good, Johnson gives us proposals ever so difficult to implement that might well do some good. The pessimistic among us will say that we will end up testing the Isaac and Armat propositions and, predictably, find them wanting.

Is there any way out? One glimmer of hope -- I would not put it stronger -- is that the states, as a result of their present fiscal crises, may have to break with their usual practices. Perhaps the need to radically revise budgets will at last force even timorous governors to close down the remnants of one-time 5,000 bed institutions that now have 75 beds, and shift the funds to community clinics and residences. For the relatively small number of the mentally ill who are suicidal or truly violent, more secure community-based facilities could provide the necessary treatment and protection. But in this fiscal climate, will federal or state governments redirect, let alone increase, funding for community care? And even if financial support is forthcoming, will the community mental health clinics spend them on others beside the worried well?

Another flicker of promise comes from the recent efforts of legal advocacy groups to turn themselves into service providers, as they retreat from litigation. Attorneys, social workers, and developers have formed effective alliances on behalf of the homeless in general and the mentally disabled among them in particular. These efforts to provide housing and social services may redound to the benefit of ex-mental patients. Yet it typically requires six or seven years to identify a site, raise money for renovation, receive community approval, carry out the renovations, and finally open the door to forty or fifty clients. So one ought not to expect immediate results.

These are, admittedly, modest hopes. We have discovered over these past three decades that the presence of misery in our midst does not necessarily provoke ameliorative action. Apparently, we underestimated the great number of our fellow citizens who can tolerate the daily sight of pain without flinching. Occasionally, a campaign is mounted that betters the life chances of one group among the disadvantaged. We have done more for persons with mental retardation than for those with mental illness, perhaps because the families of the retarded are more politically active, perhaps because persons with retardation have an appeal that cuts across political lines, even to the point of engaging the concern of right-to-life groups (who fear that neglect would promote the legitimacy of selective abortion). But the lessons learned from the occasional success -- that the mentally disabled can enjoy life in the community, that group homes can be monitored and quality maintained, and that costs of care can be kept reasonable -- do not inform or dictate policy toward the mentally ill.

Ultimately, it is not greater coercion or a new kind of administrative structure that we need so much as a commitment to meet our responsibilities to those in need of care. Here and there an individual, a foundation, or a religious organization does its part, providing housing along with medical, social, and psychiatric services in the community. But given the enormity and complexity of the problems in design and delivery, responsibilities will have to devolve on government and, in a larger sense, on an alert public. For the mentally ill are unlikely ever to wield enough influence by themselves. To be sure, ex-mental patients and their families have over the past decade fashioned their own organizations, but they have not, and by reasonable expectation, cannot, on their own, profoundly affect the course of politics. Even by comparison with other minorities, including persons with HIV disease, they exert relatively little influence.

We are left with the question of whether the democratic process will serve a population that is politically weak and publicly stigmatized. Our history does provide occasional examples of such largesse of spirit and vision, but it is difficult now to identify the persons or groups that will bring these characteristics to our own polity. It may well sound old-fashioned to invoke the possibility of enlightened leadership, capable of arousing the public conscience. But I see no other way out of the morass that entangles us.