Bring Back the Asylums

Homelessness is a complex issue. At the very least, America is not dealing with it constructively. If the nation’s blue cities are littered with homeless encampments, and if no one seems to know what to do about it, we are sorely in need some rational thought about the question.

And that is what medical ethicist David Oshinsky provides us in the Wall Street Journal. Kudos to him for a comprehensive analysis of the problem.

Hundreds of thousands of homeless people foul the environment and contribute to a rising inner city crime rate. About that there is little doubt.

Many of them are mentally ill, and are obviously not being treated. And yet, the issue of treating the homeless, and especially of treating people who might not want to be treated, has long bedeviled the nation. 

In the past, we had asylums to treat these patients. But, that occasionally involved involuntary commitment. These were state psychiatric hospitals.

Massive, architecturally imposing, and set on bucolic acreage, they housed close to 600,000 patients by the 1950s, totaling half the nation’s hospital population. Today, that number is 45,000 and falling.

In the early sixties, President John F. Kennedy signed a bill called the Community Mental Health Act. It was designed to empty the asylums and to have the community take charge of the mentally ill.

The legislation was a response to reports of the horrors committed in asylums, but it was also a response to the discovery of new classes of psychiatric drugs, from neuroleptics like Thorazine to antidepressants like Anafranil. With these medications even schizophrenics could live their lives outside of the asylums.

Oshinsky explains:

A seemingly revolutionary solution soon appeared—a new drug with the potential to treat psychotic disorders such as schizophrenia and bipolar disorder. First marketed in 1955 under the brand name Thorazine, it became the psychiatric equivalent of antibiotics and the polio vaccine. Why keep patients locked away in sadistic institutions when they could be successfully medicated close to home?

The promise of Thorazine coincided with a dramatic assault upon traditional psychiatry led by radical critics such as Michel Foucault and Thomas Szasz. Asylums existed to enslave those who ignored society’s norms, they believed. Who could say with assurance that the people locked away in these places were any more or less insane than the authorities who put them there? It seemed a perfect fit for the 1960s, appealing to emerging rights groups and a counterculture scornful of elites. “If you talk to God, you are praying,” Szasz declared. “If God talks to you, you are schizophrenic.”

As it happened, communities were not prepared to deal with schizophrenics. Besides, many patients refused to take their medication. The Achilles heel of the new policy was that it relied on patients being willing to accept their medication. At times, they needed to take it daily; at times they could take it weekly or monthly. Often they did not want to take it at all. And this does not address the side effects of neuroleptics, like tardive dyskinesia. 

Closing the asylums was the easy part. Getting people to accept a mental health clinic next to their local church or elementary school proved a much tougher sell. Asylum inmates returned home to find their former neighbors unprepared and often unwilling to help. Most of the clinics never materialized. And the promise of Thorazine was blunted, in part, by its nasty side effects. Surveys of those released from state asylums found that close to 30% were either homeless or had “no known address” within six months of their discharge. One critic likened it to “a psychiatric Titanic.”

The mentally ill gained rights, but they were often untreated. Allowing them the freedom to live as they wished sounded like a great idea. And yet, many of the mentally ill preferred to live on the streets and to make a living by committing petty crimes.

As for those who are dangerous, perhaps we will need to return to involuntary commitment. From Adam Lanza to Jared Loughner… no small number of mass murderers were diagnosed as schizophrenic and as homicidal. And yet, their psychiatrists could not have them committed to psychiatric institutions. The American legal system erred on the side of their rights and many people died.

The questions her case raised, however, are more relevant than ever. How does a civilized society deal with severely mentally ill people who refuse assistance? What constitutes the sort of behavior that requires forced hospitalization? Is it time to bring back the asylum?

These issues are intertwined with a fundamental change brought about by deinstitutionalization. Put simply, civil libertarians and disability rights advocates have largely replaced psychiatrists as the arbiters of care for the severely mentally ill. And a fair number of them, with the best of intentions, seem to view the choices of those they represent as an alternative lifestyle rather than the expression of a sickness requiring aggressive medical care.

And, of course, in many cases the alternative to asylums is prison.

The enormous vacuum created by deinstitutionalization has been a calamity for both the mentally ill and society at large. The role once occupied by the asylum has been transferred to the institutions perhaps least able to deal with mental health issues—prisons and jails. The number of inmates in the U.S. in 1955 was 185,000; today, that figure is 1,900,000.

Unsurprisingly, the nation’s three largest mental health facilities are the Los Angeles County Jail, the Cook County Jail in Chicago, and Rikers Island in New York City. Approximately one quarter of their inmates have been diagnosed with a serious mental disorder.

And yet, today's state mental hospitals are inadequate to the need. In part, this explains our homeless crisis, something that is being aggravated by the influx of illegal migrants. 

Anyway, Oshinsky’s recommendation, that we open more psychiatric hospitals, feels reasonable. It is far from obvious that we can easily treat those who are suffering from severe or chronic mental illness. Without a hospital system, it will be nearly impossible. By now we have learned that our most recent experiment has been a rank failure.