The Asylums on Our Streets

How America Continues to Fail the Mentally Ill

July 2021

Script

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There are few things that creep Americans out as much as asylums. And when you know the history...you begin to understand why.

The conditions in these institutions could be horrifying.

One famous facility in West Virginia housed nearly 10 times more patients than it was built to hold. It was so short on space that it kept many of the patients in cages.i

Data from the 1950s shows that two-thirds of the psychiatric patients treated in mental institutions underwent either electroshock therapy, comas intentionally brought on by insulin overdoses, or lobotomies.ii

It was terrible.

So, beginning in the 1960s, we shut them down.

Just one problem: When we got rid of the asylums, we replaced them with a system that may be even worse.

Why did America suddenly decide to reject mental institutions in the middle of the 20th century? Part of the explanation was journalistic exposés that brought the conditions within them to the attention of the public.

But there was also another factor at work: We thought we didn’t need them anymore. The development of the first generation of antipsychotic drugs convinced many Americans that the mentally ill no longer needed to be in institutions; that they could be sent home and treated in their communities.

It was a deeply humanitarian impulse...and it went horribly, horribly wrong.

There are over 51 million Americans who suffer from some form of mental illness. iii The vast majority of those, however, have ailments that are perfectly manageable with proper care. Many of them have conditions so subtle you’d never know they’re sick.

The real difficulty lies with a much smaller group: the 8.3 million Americans suffering from severe mental illness.iv

What’s the difference? Severe mental illness refers to afflictions such as schizophrenia, severe bipolar disorders, or the most catastrophic forms of depression—ailments that, when left untreated, leave people unable to take care of themselves.

And a lot of them are going untreated: somewhere between 40-50%.v

Why so many? Part of the reason is that many of them suffer from a condition called anosognosia.vi It’s a fancy word with a simple meaning: they don’t actually realize they’re sick.

As the mental health advocate D.J. Jaffe wrote:

"When people with mental illness walk down the street screaming, 'I am the Messiah,' it is not because they believe they are the Messiah. They know it. They are totally unaware they are ill.”vii

If individuals in such dire circumstances don’t know they’re sick, how can they be expected to be responsible for getting the treatment they require?

The obvious solution would be to entrust their care to loved ones. But medical privacy laws prevent doctors from disclosing to family members both the diagnosis of a severe mental illness and any medications that have been prescribed. The only people who can help are kept almost completely in the dark.

The result: The severely mentally ill are no longer suffering in asylums...they’re just suffering everywhere else.

While they make up only about 5% of the country’s population, they’re about 30% of America’s homeless population.viii

And many who aren’t on the streets...are behind bars. In 44 states, a jail or prison holds more mentally ill individuals than the largest state psychiatric hospital. ix

In fact, any honest accounting of the numbers would show that the three largest mental institutions in America are the Los Angeles County Jail, the Cook County Jail in Chicago, and the jail at Riker’s Island in New York City.x

Real compassion would involve policies that aim to help the mentally ill—not to leave them alone and tortured by their illness.

Thankfully, we know what some of those policies are: programs like Assisted Outpatient Treatment (AOT)—which allows courts to compel treatment, in the community, for people who otherwise won’t get help.

AOT programs can be transformative. Amongst those who participated in New York, their rates of homelessness went down 74%; their rates of incarceration went down 87%.xi But too often these programs are short on resources or underutilized—meaning they help far fewer people than they could.

And they’re only part of the puzzle. Policymakers will have to change laws to empower family members to adequately care for their loved ones. And for the sickest individuals we may even need dedicated facilities to play the role asylums were once supposed to. After all, if hospitals were as dangerous and dysfunctional as the mental institutions used to be...would we have just gotten rid of all of them? Or would we have built better ones?

When we look back at the rotting asylums of an earlier generation, we find it hard to believe we ever treated the severely mentally ill with so little compassion. But if, in the present day, we continue to relegate the mentally ill to prison or the streets rather than getting them the help they deserve...will future generations judge us any less harshly?

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