Now is a far better time to be mentally ill than it was a few hundred years ago. Institutions like the infamous Bedlam were not happy places, and you might just find yourself chained to the wall for years on end.
In the 1800s, you may have ended up in the Trans-Allegheny Lunatic Asylum in Weston, West Virginia for “imaginary female troubles” or “fits and desertion of husband.”
In the early 1900s, Dr. Henry Cotton, head of the New Jersey State Hospital at Trenton, started doing surgeries to remove rather crucial body parts (like the colon) from the crazy folk, most of whom died afterwards.
Deinstitutionalization in the US
Moving mentally ill people out of the institutions where they’d been locked up seemed like a good idea. In 1963, the United States enacted the Community Mental Health Act, John F. Kennedy’s 3-year plan to move people out of “custodial isolation” in asylums and back to the community. Community mental health centres were supposed to take over care
Of course, the funding didn’t come close to matching the need. The most severely ill fell through the very wide cracks, producing homelessness and a shift to the correctional system in mass numbers. President Ronald Reagan later furthered deinstitutionalization and slashed funding to support the mentally ill, which of course only worsened the problem.
Reagan-era legislation also shifted decision-making around involuntary committal from medical professionals to the courts. While that could have been a good thing, in practice, it made it more difficult to commit people. That’s great if it’s keeping people out of hospital that don’t need to be there; however, it’s not so good when it’s highly vulnerable people who don’t have other options.
Then you get situations like the documentary God Knows Where I Am. It tells the heartbreaking story of a woman whose bipolar psychosis couldn’t be treated in hospital because that would have required a guardianship order, which a court would not approve. Since the hospital’s hands were tied, they discharged her. She lived for three months squatting in an empty house before starving to death in the wintertime.
While deinstitutionalization is absolutely good for people who don’t need it, there are a lot of people who can end up falling through the cracks without adequate community supports. In the city where I live, closure of the major provincial psychiatric hospital, a process that happened over a few decades, contributed significantly to my city’s large skid row population. Here as in elsewhere, deinstitutionalization has led to significant increases in homelessness.
Some people have very high care needs due to their mental illness. Promoting independence is generally a good thing, but for people who don’t have the capacity, independence simply means their needs don’t get met, like the need for safe shelter, healthy food, personal hygiene, etc. That’s not necessarily a better life than living in a setting that meets their care needs.
I’m by no means arguing for people to get locked up in institutions on masse. However, not providing adequate support could mean getting locked up somewhere else; in the U.S. in 2003, there are more than three times as many people with mental illness in the prison system as in psychiatric hospitals (figure from Cornell University). The massive jump in numbers of mentally ill in correctional facilities happened at the very same time that psychiatric institutions were closing.
Is there a better way?
Better funding for community mental health would make a big difference. Somewhere, I think there’s a balance to be found between offering people the level of support they need to function without being more restrictive than necessary. Choice is important, and autonomous decision-making doesn’t always mean independent living. People are able to thrive when the level of support they get matches what they need. When you dump people into independent community living and they don’t have the skills, and perhaps don’t have the capacity, it isn’t going to help them thrive. It’s more likely to help them be that scary crazy person who seems to fit all of those scary crazy people stereotypes that people hold. It’s probably not what anyone had in mind with deinstitutionalization.
Where do you think the balance might lie between giving people the support they need without overstepping?