Deinstitutionalization - The Rise and Fall of Mental Health Institutions In America

The Rise and Fall of Mental Health Institutions in America: A Story of Triumph and Tragedy

The 1950s marked a pivotal turning point in American mental health care. Over the span of just a few decades, hundreds of thousands of people with mental illness were discharged from state hospitals in what became known as deinstitutionalization. For some, this represented a long-overdue triumph over the harsh treatment found in asylums. For others, the results were nothing short of tragic.

 Before the Asylum Era

Prior to the introduction of asylums in America, people with mental illnesses typically received care from their own families. When family care wasn't possible, they might be placed in alms houses or small hospitals funded by wealthy benefactors who had family members in these facilities. Tragically, many others found themselves imprisoned. In 1750, at least five known mentally ill individuals were held in Williamsburg's public jail.

The first state hospital in the United States opened in 1773, but such institutions remained small and rare. The Eastern State Hospital in Williamsburg, Virginia, initially housed only five patients. However, these hospitals experienced rapid growth—by the 1860s, the Williamsburg facility had expanded from five patients to 238.

The Reform Movement Takes Hold

The 1800s brought passionate advocacy for psychiatric hospitals, led most notably by Dorothea Dix. Her visits to jails and alms houses across multiple states revealed horrific conditions for mentally ill inmates. In Massachusetts, she documented her findings with stark clarity:

*"I proceed gentlemen briefly to call your attention to the present state of insane persons confined within this Commonwealth in cages, stalls and pens, chained, naked, beaten with rods and lashed into obedience."*

Dix's tireless efforts resulted in the establishment of 30 hospitals dedicated to treating the mentally ill. Thomas Kirkbride, superintendent of the Pennsylvania Hospital, developed the influential "Kirkbride plan" for moral asylums—facilities built in secluded areas with long wings designed to provide privacy and comfort. These asylum cells were specifically adapted to feel welcoming rather than prison-like.

By the 1870s, virtually all states operated one or more such asylums.

 The Dark Side of Early Treatment

Despite good intentions, early psychiatric treatment was often brutal and ineffective. With limited understanding of mental health, doctors in the early to mid-1900s believed their medical procedures would restore physical balance to the body and brain. However, these treatments lacked any scientific foundation.

Patients endured lobotomies, induced seizures (known as convulsive therapy), bloodletting, and purging to "cleanse" supposed impurities from the body. These procedures rarely provided positive effects and frequently resulted in memory loss, physical damage, or death. Electricity machines shocked patients, drugs were used to exhaust them, and tranquilizing chairs restrained them. Asylum doctors essentially experimented on patients in their desperate search for effective therapies.

As one observer noted: *"Bed would follow upon bed crammed into the most extraordinary narrow spaces, day rooms filled with people... this is the assignment given to the State Hospital: you handle the failures, you handle those who we could not cure."*

The System Reaches Breaking Point

By the early 1900s, hospitals were severely overloaded. More patients meant higher operating costs, and by 1955, the number of patients in public psychiatric hospitals peaked at 560,000. Many facilities were overcrowded but lacked adequate government funding, making it impossible to provide patients with the individual attention they desperately needed.

 The Winds of Change

The late 1940s brought renewed efforts to establish small community mental treatment facilities as alternatives to costly state institutions. The game-changer came in 1952 with the introduction of chlorpromazine, commonly known as Thorazine—the first truly effective anti-psychotic medication. This breakthrough offered hope for treating even the most severe psychiatric symptoms and led many to question the necessity of large mental health institutions. After all, why maintain expensive institutions when a drug could potentially cure mental illness?

As one expert explained: *"Deinstitutionalization has been around more than 50 years, probably closer to 60, and it can be attributed to the need for social change in the way we care and support people with serious mental illness... breakthroughs involving the use of psychotropic medications... and financial implications where state governments were putting their dollars."*

 The Political Push

By the end of the 1950s, pressure mounted against state institutions as social norms evolved. Society no longer accepted that people with mental illnesses should be locked away indefinitely. The civil rights movement of the 1960s brought activists to the streets, and deinstitutionalization found its way into courtrooms across the nation.

The movement gained a powerful ally in President John F. Kennedy, whose sister had been institutionalized. In 1963, Kennedy signed the Community Mental Health Act, declaring:

*"30,000 persons in our state mental hospitals... many of these institutions have less than half of the professional staff required. Forty-five percent of them have been hospitalized for 10 years or more. If we launch a broad new health program now, it will be possible within a decade to reduce the number of patients now under custodial care by up to 50%."*

Although this act was never properly executed, its intended purpose was to fund community-based preventative care and initiate the shift away from institutions.

 The Unraveling

Deinstitutionalization proceeded at full speed, but lack of funding created significant obstacles. The 1965 passage of Medicaid excluded coverage for people in institutions for mental diseases, effectively forcing people to leave these facilities. The 1980 Mental Health Systems Act, signed by Jimmy Carter to revise community mental health care systems, was short-lived. In 1981, Ronald Reagan's Omnibus Budget Reconciliation Act repealed Carter's community health legislation, slashing federal mental health funding by a staggering 30%.

 The Mixed Legacy

When properly funded, small community-based health facilities proved beneficial for people with mental disorders. These programs granted patients more rights, freedoms, and choices about how to live their lives. People with mental illnesses could integrate into society rather than being sent away. Some maintained jobs, others enjoyed regular contact with friends and families—opportunities that would have been impossible while living in an asylum.

However, deinstitutionalization was fundamentally flawed in crucial respects. As one critic observed: *"It assumed that there was a community that was willing, able, ready and prepared to receive mentally ill people and provide them with a complete range of supportive services."* Due to the nature of severe mental illnesses, many patients were poor candidates for community-based care.

 The Tragic Consequences

One of the main flaws of deinstitutionalization was that patients who had lived full-time in state asylums weren't guaranteed anywhere to live after facilities closed. Unless they had family to return to or financial security to live independently, former patients often had nowhere else to go but the streets. Mental health became one of the top three causes of homelessness.

Disturbingly, many people with mental illnesses ended up in jails. Even today, ten times more people with severe psychiatric diseases are behind bars than in state hospitals. These prisons and jails are no better equipped to support the needs of mentally ill people than the streets.

 Lessons from History

The history of mental health care in America represents a series of both tragedies and triumphs. From Dorothea Dix to John F. Kennedy, people with the best intentions attempted reforms that worked only to some extent. Sometimes, as this story illustrates, triumph and tragedy prove to be cyclical forces in the ongoing struggle to provide compassionate, effective care for society's most vulnerable members.

The challenge remains: How do we learn from this complex history to build a mental health system that truly serves those who need it most?