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Mental Illness on the Streets

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From 1978 to 1983 I worked at Du Pont, which had a famous slogan: “Better things for better living through chemistry.” Andrew Scull’s Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental Illness (Harvard University Press, 2022), shows how those years were the culmination of a “better drugs for better living” approach to mental illness that led to closing asylums across the United States”—and left many of the sickest among us homeless.

Scull shows how asylums originated with “the great moral entrepreneurs” of the nineteenth century, reformers like Dorothea Dix and Horace Mann. By 1955 more than a half million mentally ill humans lived in state hospitals. The largest single item in state budgets, mental hospitals “absorbed as much as a third of many states’ revenues.”

Some of the hospitals were “desperately short of attendants” and awful in many ways. Byberry State Hospital in Philadelphia had an “incontinent ward” where men were “picking their way across a concrete floor amid puddles of urine and piles of excrement.” Journalist Albert Deutsch called Napa State Hospital in California a “gingercake monstrosity… a dangerous firetrap,” and described how in Detroit “many patients were strapped to their beds by leather thongs.”

Asylum superintendents welcomed Deutsch and photographers, thinking his words and their pictures would move hearts and help the hospitals “secure huge amounts of new funding to turn them into the therapeutic institutions they purported to be.” Those hopes were dashed because of two developments, one political and one purportedly medicinal.

The political development was the Republican nomination of Barry Goldwater in 1964 and the consequent landslide victory of Lyndon Johnson, who with a massive Democratic edge in Congress secured passage of Medicare and Medicaid in 1965. Scull notes that these benefits would not be “paid to any one resident in a state institution. As state bureaucrats came to realize…, these funds could replace state expenditures on the mentally ill, provided patients were discharged from the state hospitals and placed elsewhere.”

The medicinal development followed on the discovery that insulin could treat diabetes, and antibiotics could be a lifesaver concerning physical disease: why couldn’t drugs cure mental disease? Manic episodes? Use lithium. Clinical depression? At the end of the twentieth century Vice President Al Gore’s wife, Tipper, summarized the popular understanding: “What I learned is that your brain needs a certain amount of serotonin and when you run out of that, it’s like running out of gas.”

Simple, clear—and wrong, as recent research has shown. Yet, Tipper was sensibly seeking a tipping point: If all we are is Biology, then Biology will fix us.  From 1955 to 1965 the number of asylum inmates declined by 15 percent as states facing budget pressures and falling into pill determinism trimmed the mental hospital population from 558,922 to 475,202. And, once state officials realized the federal government would pick up the bill, inmate population from 1965 to 1980 plummeted to 132,164, a 72 percent drop.

Scull’s summary: “As the decline of the asylum accelerated, the public was assured that deinstitutionalization constituted a grand reform. Patients who had languished on the back wards of mental hospitals were being returned to the community, thanks to the advent of modern drug therapy. The horrors of the madhouse were rapidly becoming a thing of the past. Community care would prove at once more humane and more effective. Mental hospitals were portrayed as places where social skills atrophied.”

That was true. The hospitals often were bad, but turning Biology into God had a savage side. Scull: “The decanting of mental patients into the community… took place with virtually no advance planning.” Community Care “was a shell game with no peas. In place of forcible confinement in publicly run asylums, the chronically mentally ill were abandoned to their fate.”

Their fate, as became evident in the 1980s, was homelessness. In 2022, all of us in person or by video can see the tent cities and the even worse sight of virtually catatonic drug victims in cities where the homeless don’t have tents. Scull’s bottom line: “’Community care’ has turned out to be an Orwellian euphemism masking a nightmare.”

Tomorrow I’ll have more about Scull’s book in my monthly Olasky Books newsletter. Next Friday on Fix Homelessness I’ll have more specifics about what went wrong and why.