“Those who cannot remember the past are condemned to repeat it.” George Santayana
In true Dickensian fashion the U.S. began shoving the mentally ill into jails and almshouses in the 18th century as a “solution” to the inconvenience of their behaviors. The almshouse sheltered the insane, physically handicapped indigent adults and even children.
The Rev. Louis Dwight created the Boston Prison Discipline Society in 1825. He denounced jail conditions and advocated passionately to create hospitals for the mentally ill.
Dorothea Dix took up Rev. Dwight’s cause, telling the Massachusetts Legislature in 1842 that “Prisons are not constructed in view of being converted into County Hospitals, and Alms-Houses are not founded as receptacles for the Insane”. Thus began her crusade to build hospitals where mentally diseased people could receive good care and living environments.She traveled from Boston down the east coast to mobilize public opinion that people with mental illness were sick and needed care, not jails.
Rev. Dwight, Dorothea Dix and their fellow advocates succeeded in convincing the federal government to build asylums. This institutional inpatient care model, in which many patients lived in hospitals and were treated by professional staff, was considered the most effective way to care for the mentally ill. Institutionalization was also welcomed by families and communities struggling to care for mentally ill relatives.
By the end of the 1800s communities were building asylums that were attractive and provided good care. A well known architect of the Athens Asylum developed a model in which they took on the feel of a home, with individual patient rooms and homey décor. What they didn’t do was establish criteria for admissions. By the 1950s the inpatient psychiatric population had reached 560,000, an unsustainable trend.
At the same time advances in medications gave hope that more people could live outside the hospitals. Thus began the process of de-institutionalization. Literally hundreds of thousands of patients left hospitals for “more independent” living. Outpatient support services combined with new psychotropic drugs would allow people with mental illnesses to thrive in the community.
Giving people the opportunity to enjoy a life outside of the hospital is a noble effort, and has worked for many. But the fundamental place for care – the psychiatric hospital with well trained professionals – has all but disappeared. We have reduced hospital capacity by 90%. We have undercut the system of care by going too far. This shortage of beds means it is much harder for people to obtain critical care. Clients have to wait for openings, and their stays may be as little as 24 hours. People can’t recover from the flu in 24 hours, much less a serious episode of depression or schizophrenia.
The safety net for people who are not functioning well in the community is fraying, badly. Community based treatment providers are underfunded. Caseloads are large and high staff turnover erodes our capacity to sustain experienced care. More people with mental illness are homeless. They do not get medical care, nor can they afford their medicines. More turn to drugs and alcohol to deal with their symptoms. And then they end up in jail.
Remember the call to improve the lives of our mentally disabled citizens by removing them from jails and providing enlightened, medically based care? We now find that the largest concentrations of mentally ill people are our jails and prisons.
The nation’s jails and prisons are turning into warehouses for the mentally ill, with the three largest jail systems housing more than 11,000 prisoners under treatment on any given day.
Contrary to public opinion most mentally ill people in jail are not there for violence. They are there for petty crimes often related to their needs for survival in the face of poverty and homelessness. At ICAN Housing in Canton Ohio we see the cycle repeat itself in which people will go so far as to commit a small crime in order to have a warm place to sleep and a few meals.
How far have we come from the poor houses of the 18th century? In one sense we have leapt ahead with our therapeutic treatments. It’s tragic that a society that can and should make these treatments available to all who need it choose instead to let our jails and prisons become our default homes for the mentally ill once again.