Why We Need Asylums: Rethinking Mental Health Care In America

Why We Need Asylums: Rethinking Mental Health Care in America

Standing before the abandoned Tinley Park psychiatric facility in Illinois, I'm confronted with a complex piece of American history. This last state-run psychiatric asylum opened in Illinois was built in 1958 on 213 acres with capacity for 3,500 patients and grand aspirations to expand to 5,000. Yet within just a handful of years, this institution became practically obsolete. Its capacity dwindled to only 150 patients until its budget was completely cut in 2012.

Now it stands abandoned—a real-life film set for a post-apocalyptic movie. While I won't be going inside (it's illegal and heavily guarded), adventurous explorers have captured images of its doomed interior that look like something out of a horror scene. The crumbling appearance conjures images commonly associated with asylums: lobotomies, straight jackets, padded rooms—a hell hole where people lose their autonomy and are locked away for most of their lives.

Many people might look at this facility's closing and say "good"—it marks our cultural advancement toward more humane treatment of people with mental illness. Better not to lock people away for their whole lives, right?

But when I look at Tinley Park, I feel conflicted. Because believe it or not, I think we kind of need asylums. I think their disappearance has been a net negative for mental health care. Let me take you through how we got to where we are today and where we need to go in the future.

 The Origins of Psychiatric Care

Psychiatric hospitals or asylums aren't really a modern concept. While Europe was going through their dark Medieval times, the Islamic Golden Age was producing the first psychiatric wards and a proliferation of hospitals that treated the mentally ill. Contrary to what you might expect, treatment during this era was actually quite progressive—mental illness was treated essentially the same way as any other physical ailment, with patients receiving medication, job training, and music therapy. European travelers of the time remarked at how nicely and kindly these "lunatics" were treated.

However, these specialized services were rare until the early 1800s, when standalone facilities called asylums were built in the United States and Europe to provide long-term care for mentally ill patients.

The Promise of Early Asylums

These early asylums were actually part of a new, more humane attitude toward mental health. Prior to asylums, the burden of care was placed on individual families. If families couldn't provide care, the seriously mentally ill either languished on the streets, were forced into prisons, or were exploited by workhouses. 

Even when families did seek care, there was often a big disparity based on financial status. The rich could afford specialized services at hospitals, while the poor had to rely on scant resources from religious institutions or charities. Typical care for the mentally ill in 1700s America often involved putting people in "mad houses" where they were shackled to walls in basements, put in solitary confinement, or regularly beaten if they acted out.

This horrid treatment was largely due to how mental illness was viewed at the time—the mentally ill were considered social deviants or moral misfits suffering divine punishment for some inexcusable transgression. If you were mentally ill, you were a horrible person and deserved it.

The Moral Treatment Movement

The asylum, as the word implies, was built to be a refuge—a safe haven, a sanctuary for mentally afflicted people. These centers sprang up in the wake of the moral treatment movement, which marked a cultural shift in how we thought about mental health. No longer was lunacy the mark of a damned soul, but instead an illness that could be cured.

In the United States, people like Benjamin Rush and Dorothy Dix championed moral treatment, which believed that if you served the mentally ill in a humane and kind way in spacious, well-ventilated hospitals on beautiful grounds, these people would recover and eventually be cured, or at least have their symptoms alleviated.

This idea took off, leading to the opening of over a hundred state-run asylums around the United States. In these asylums, physical restraints were way less harsh and less frequent. After a patient died from strangulation by his straight jacket in 1829, asylums enacted significant reforms that led to the reduction or total abolition of physical restraints. No solitary confinement, no regular beatings, no shackles—just quiet, secluded hospitals in peaceful countrysides where patients could relax and even work if they wanted to.

*Note: I don't want to give the wrong impression that early 1800s asylums were some sort of mental health utopia. They were definitely progressive and provided top-notch care for their time, but they were still a product of their time. What were once state-of-the-art treatments would today be considered horrifying acts of straight-up abuse, with many practices and experimental treatments that would be illegal today.*

The Decline Begins

Unfortunately, this period of psychiatric enlightenment didn't last. By the end of the 1800s, asylums came under siege. Local governments redefined senility as a psychiatric problem and began funneling elderly residents from their almshouses into state-run asylums so they didn't have to pay for their care anymore.

This exponentially increased the number of patients in each facility, going well above and beyond their physical and financial capacity. States refused to set aside the resources or budget necessary to provide acceptable care. Not to mention, asylums were specialized to treat individuals with serious mental illnesses like bipolar disorder, schizophrenia, and major depressive disorder—not geriatric patients with Alzheimer's and dementia.

This rapidly changed how asylums operated. They became overpopulated, underfunded, and filled with patients who couldn't recover in an asylum setting. This properly broke people's optimism around the effectiveness of moral treatment because treatment in asylums no longer followed its original tenets.

In these newly overcrowded, understaffed asylums of the late 1800s, patients stopped receiving high-quality, personalized care. Operators once again returned to the use of restraints, padded cells, and sedatives as a form of crowd control. Asylums became custodial rather than therapeutic settings.

The Darkest Chapter

The degradation continued. By the early 1900s, the eugenics movement further shifted public sentiment around mental illness in a negative direction. Eugenicists believed that psychiatric disorders were marks of inferior genetics and should be bred out of the population. The asylum transformed from a safe haven for the mentally ill to recover into a holding facility where supposedly inferior people were segregated from the rest of society so they couldn't reproduce.

Over 18,000 people were forcefully sterilized in asylums during this time—probably one of the darkest periods in asylum history.

Women were disproportionately represented in asylums because it was shockingly easy for men to have their wives or daughters committed for pretty much any reason. The lunacy laws of the time included misogynistic diagnoses that supposedly required involuntary incarceration, including "hysterics" or "female disease." Any marginalized group—Native Americans, Black Americans, pretty much anyone who didn't fit into mainstream American society—were more often placed in asylums as a way of getting them out of the way.

This view of the mentally ill also allowed psychiatrists to experiment upon this population with a variety of new and untested medications and therapies.

Add the Great Depression and World War II, which cut state budgets across the board and produced staffing shortages at these institutions, and it's easy to see how asylums declined into appallingly unethical, corrupt, and detrimental places for patients.

 The Seeds of Change

During the war, some conscientious objectors were assigned to conduct their public service at these asylums and ended up revealing many abuses throughout the system. Some patients even died of starvation. This led to significant reform in the 1940s and 50s and the creation of the National Institute of Mental Health (NIMH) and the National Mental Health Foundation, which eventually became the National Association for Mental Health (NAMI).

Due to this increased attention, the legacy of asylums became that of poor living conditions, awful hygiene, and abusive treatment of patients. Those criticisms were right—asylums were generally awful places to live at that point. They really seemed like prisons operating with a medical veneer.

 The Push for Deinstitutionalization

It's no surprise that by the 1950s and 60s, there was a huge movement calling for asylum closure. Asylums were at their height in 1955 with about 560,000 people living in them, but the winds had shifted.

In 1954, a new drug called Thorazine was released that seemed able to treat psychosis. Suddenly some of the most severe symptoms could be ameliorated, making people think that maybe inpatient psychiatric care wasn't so necessary. This medication was also widely used in asylums, though opponents viewed it as a kind of "chemical straight jacket" because of its fast-acting sedative effect and gnarly side effects, particularly tardive dyskinesia.

Around the same time, a new system of nursing homes began opening to meet the needs of older patients, and there were more specialized programs for those who had suffered stroke, paralysis, or head trauma. In 1962, the best-selling novel "One Flew Over the Cuckoo's Nest" was published, telling a dramatized and damning story of life in the asylum.

Against the backdrop of the Civil Rights Movement, which sought to incorporate many disadvantaged groups into mainstream society, there was public outcry and political appetite for change. President Kennedy's own sister, Rosemary Kennedy, had experienced significant brain damage after being lobotomized.

In 1963, Kennedy signed the Community Mental Health Act, promising to replace custodial mental institutions with Community Mental Health Centers that would allow patients to live and get care in their local communities—and it was supposed to be cheaper too.

 The Reality of Deinstitutionalization

In principle, it sounds fantastic to have individuals live locally and be integrated back into society while receiving care for all their mental health needs. But in practice, deinstitutionalization has been a train wreck.

Two years later, in 1965, the creation of Medicaid opened up huge federal funds for medical care but excluded coverage for inpatient care in institutions for mental disease. This was a ploy to further encourage Community Mental Health Care and supercharged deinstitutionalization because now state governments were incentivized to save money by moving patients out of their mental hospitals into other federally funded programs.

The only problem? Kennedy's mental health vision was never fully realized. Few Community Mental Health Centers were ever built, leading to a huge shortage in care. Patients who had lived in asylums sometimes for years or even decades were sometimes suddenly cut loose into the public and expected to either sink or swim.

Some got care from hospitals or nursing homes, some could rely on their families or were lucky enough to find Community Mental Health Services, but many were just dumped onto the streets with nowhere to go.

Jimmy Carter attempted to reform and restructure the community mental health model in 1980, but his act was promptly obliterated by Ronald Reagan the next year, who slashed the mental health spending budget by 30 percent and effectively ended all direct federal funding for the promised Community Mental Health Services.

The Current Crisis

If the goal of deinstitutionalization was simply to close inpatient services, then it's been a raging success. The number of psychiatric beds dropped 95 percent from 1955 to 2005, with a further 25 percent reduction in psychiatric hospitals since 1997. As of 2015, there are fewer than 200 state-run psychiatric hospitals in the whole country, leaving only 14 beds for every 100,000 people.

The services in place right now simply are not enough. These days, outpatient treatment for the severely ill is either completely unavailable or a month or more away. Nearly 40 percent of adults with serious mental illness receive zero treatment. This leaves many people with two options: either rely on family or fend for yourself.

It feels like we're going back to 1700s standards, with serious mental illness being viewed as an individual problem rather than a societal responsibility.

The Unintended Consequences

This has led to some really unfortunate unintended consequences:

**Family Burden**: Many families report feeling overwhelmed by the care of their mentally ill loved ones with no alternatives available. This can breed feelings of resentment and guilt because families are faced with the impossible choice to either take 100 percent of their loved one's care into their hands or leave them to their own devices.

**Homelessness**: At minimum, 25 percent of unhoused Americans experience serious mental illness. This exposes them to the vicious cycle of being relocated from the streets to hospitals or jails and then released back onto the streets without any new access to care...(This is what one member of a public policy think tank called tri-institutionalization)

**Emergency Room Crisis**: This is why our emergency rooms are jam-packed with acutely ill patients.

**Prison System**: Correctional facilities have become our country's largest psychiatric care providers. Around 20 percent of individuals in jails and 15 percent of individuals in prisons have a serious mental illness—that's around 356,000 people. These are not places for the seriously mentally ill.

Hospitals can offer only about 72 hours of care, and that care is expensive and not meant to provide long-term resources to achieve independence or stability. Correctional facilities further stigmatize mental health and worsen symptoms, creating a cycle where individuals end up in the facility repeatedly.

## A Personal Perspective

I've worked in several community programs that serve the severely mentally ill, and it was really fulfilling in many ways. But it was also very exhausting, mostly because every day we were confronted with insufficiencies and major problems: not enough money, not enough staff, not enough housing, long wait lists, or straight refusals to potential clients in real need because we were at capacity.

Some clients did really well and thrived in community services, but many struggled and ended up back in the vicious cycle despite having regular checkups, a place to live, medications, therapy, and other resources. From time to time, we would refer the most vulnerable clients to state psychiatric hospitals, but almost every time they would be denied—no matter how severe the case was, there simply was not space.

## The Need for Balance

I think the deinstitutionalization movement was really well-intentioned, and I'm a firm supporter of placing people in the least restrictive setting needed for their care and betterment. We shouldn't be putting people into inpatient care who don't need it, and it's clear that Community Mental Health Care is a superior approach for many of the mentally ill.

But it's also clear that the pendulum has swung too far in the other direction. As with any kind of medical care, we need a continuum of care that ranges from outpatient care to community services and supportive housing to inpatient medical care. It's not enough to just put everyone out in the community.

It's estimated that 8 million Americans suffer from severe mental illness. Not all of those—or even most—will require inpatient long-term care. However, it's important to recognize that the needs of the seriously mentally ill vary in nature and intensity, and it's obvious that we need substantially more than what we have now, which is only about 43,000 beds.

## Bringing Back Asylums—But Better

Just to clarify: when we're talking about these facilities and long-term care, we're not talking about committing people and never letting them leave. In fact, it's the opposite. The goal is to help people get better at this higher level of care so they can step down. For many people, they may need just a few days or maybe a few weeks to recover and then be handed off to a lower level of care. Some may need a few years—it depends on the individual client's situation. These facilities are not holding facilities or custodial facilities.

Let me be clear: I am not nostalgic for the asylums of the 1950s. But we need to open up significantly more long-term inpatient psychiatric hospitals. We need to bring back asylums—but better.

## What Would Better Look Like?

I would like to return to the original meaning of the word asylum. It should be a sanctuary, a safe haven for vulnerable people. It should be a therapeutic place, not custodial, where the seriously mentally ill can stabilize and recover.

Realistically speaking, this means:

- **Government-funded asylums** that provide high-quality and ethically administered long-term psychiatric care

- **Insurance coverage**, particularly Medicaid

- **Regular oversight** to prevent opportunities for abuse or harm to patient (Key point. This is part of the reason the old asylum system was shut down.)

- **Patient-centered, evidence-based, and integrated care**

- **Community integration** rather than isolation in the countryside

I sort of imagine them being comparable to modern memory wards for patients with dementia, who now experience significantly improved quality of life thanks to environmental, medical, and therapeutic advances. I'm imagining facilities that provide structure and include daily living skills, vocational skills, and recreational outlets. The priority would be to ensure the highest level of patient safety, care, and autonomy.

 The Economic Reality

I know some of you are thinking this sounds expensive, and you're right. But you know what's even more expensive? Paying for prison beds, police labor, court costs, and emergency room visits. Research has found that it's almost always less expensive to actually address the underlying issues that result in individuals using these resources inappropriately compared to continuing to ignore the problem and hope it goes away.

There will always be people who need extra mental health support. We can't continue to abandon the people who are most vulnerable in our country. Investing in the systems needed to support these individuals isn't just good for them—it's good for our communities, our families, our society, and our humanity.

 Beyond Asylums

This is only one small part of our mental health system. While this is the most costly and vulnerable mental health population, it's far from the only group that needs extra support. Many people don't access therapy because the cost of co-pays is too high. Essentially, our country's whole mental health system needs to be revamped and better funded.

 Looking Forward

Standing here in front of Tinley Park, I can't help but wonder whether it's time to dust off this ghost of a bygone era—but this time, do it better. Keep it focused on its original purpose, its original ethos. The field of counseling has come a long way since the 1950s, and with everything science and medicine are learning about the brain and how it works, I really think that right now we have the knowledge and tools to create something better.

The question isn't whether we need more mental health resources—we clearly do. The question is whether we have the will to build them.