As long as there has been illness, there has been mental illness. And as long as there has been mental illness, there has been problematic treatment of mental illness.
In 1796, hundreds of years before the advent of modern psychotherapy and medications, a seemingly revolutionary event in the field of mental healthcare management occurred when opened the Retreat in York, England. Tuke, a Quaker and an abolitionist, had some new ideas of how to treat mental health. These ideas were reflected into the model of the Retreat, which was a non-profit psychiatric hospital in England dedicated to the treatment of the mentally ill through the "Moral Treatment" approach.
Moral Treatment essentially meant treating people with mental health needs as people. Patients at the Retreat received personalized attention and therapy aimed at improving their social skills, self-control, and self-worth. Physical restraints and harsh discipline were disallowed, as the Retreat aimed to have their patients treated as any other humans would be.
Tuke's Retreat inspired a number of other Moral Treatment facilities, including the Brattleboro Retreat in Vermont and the Hartford Retreat in Connecticut. Tuke's humanity and vision had sparked a revolution in the care of mental illness. Or at least that's how it seemed.
Tuke's vision of mental health care was gentle and compassionate. It was also expensive and labor-intensive. As time went on and the Industrial Revolution forever changed life for Americans, the need for mental health care exploded.
Throughout the 19th century, the number of Americans in mental institutions increased nearly tenfold, to over 150,000 by 1904. There were simply not enough resources to treat all the new patients, and conditions in mental institutions worsened as the patient population increased and funding decreased. Pseudoscientific ideas, including eugenics and phrenology, became popular ideas among psychiatrists and led to atrocities like being imposed on patients.
Whereas Tuke's ideas of mental health care were akin to an expensive handbag being handmade by caring craftsmen, institutional care by the turn of the 20th century had become more like an assembly line in a cost-cutting factory.
Revolution and Advancement
The seeds of deinstitutionalization began being sowed early in the 20th century, with the advent of early medical and surgical therapies for mental illness. Years before the discovery of penicillin, developed a treatment for neurosyphilis using malaria in 1917. Electroconvulsive therapy was introduced in 1938, not long after barbiturate drugs became widely used for issues like insomnia and anxiety. Around this time, the unfortunate practice of prefrontal lobotomies also became widely used and was seen as a therapy that could make the mentally ill more agreeable and less aggressive.
A true revolution for mental healthcare came in 1950 when , the first antipsychotic, was synthesized for the first time. Psychosis had long been one of the principle reasons for institutionalization, and now, it had seemed, there was finally a pill that could stop it. Chlorpromazine was followed by many other revolutionary psychiatric medications, including antidepressants and mood stabilizers.
Thanks to a wave of profound advancements in the early and mid-20th century, deinstitutionalization began to happen spontaneously. From 1955-1967, the number of Americans in mental institutions dropped 30%, with much of the reduction attributable to the new antipsychotics that allowed people with schizophrenia to live outside of asylums.
Mental institutions were also becoming increasingly unpopular. In 1946 , an exposé of the dilapidated, overcrowded conditions that some state mental hospitals were exposing their patients to. The exposé was complete with photos and stories of patient suffering that horrified many Americans and created a sense of urgency to help these people.
In 1963, President John F. Kennedy signed into law the Community Mental Health Act (CMHA), attempting to do just that.
An Unfulfilled Ambition
The purpose of the CMHA was to shift the setting of mental healthcare from institutes to the community, through increased funding for community-based outpatient treatment centers for mental healthcare. The CMHA was successful in facilitating deinstitutionalization, and the number of institutionalized Americans has fallen dramatically since its signing. The bill was extremely ambitious but largely failed to accommodate the massive need for community-centered mental healthcare that exploded following the release of mental health patients from institutions.
Only about half of the community centers proposed in the CMHA were ever actually built, and . President Kennedy was assassinated weeks after signing the bill, and his successors failed to pass legislation to adequately deal with this massive need for community mental health care. This left many Americans with woefully inadequate resources to treat their mental health problems. Fifty years later, it is clear that Kennedy wrote a check that his successors could not cash.
In the years following the CMHA there were many other factors that further hastened deinstitutionalization, including the advocacy of groups such as the National Alliance on Mental Illness, the landmark Supreme Court decision of Addington v. Texas, and Geraldo Rivera's 1972 exposé of . These factors made institutionalization significantly more difficult and less popular, leading to more patients and physicians preferring to have mental healthcare treated in the community setting rather than inpatient. To this day, however, community-based mental healthcare resources are far too scarce, and the consequences have been tragic.
What's Happening Now and What Can We Do?
One of the most devastating consequences of deinstitutionalization has been homelessness. At any given time, about have severe mental illness, despite only about 2% of the general population of Americans meeting the criteria for diseases like or disorder. Furthermore, many homeless people are for mental healthcare. Establishing care with a psychiatrist can take several months, especially for patients with Medicaid. Many homeless people, therefore, rely on primary care doctors, who are often reluctant to treat severe mental illnesses like schizophrenia and bipolar disorder.
The history of institutionalization and deinstitutionalization is complex and filled with good intentions and poor results. Deinstitutionalization freed many people from overcrowded, poorly managed, dirty, and neglectful facilities that were used to house the mentally ill for many decades. However, the unintended consequences and imperfect execution of American deinstitutionalization left tribulations that are still felt today, particularly homelessness.
Yet despite the grim picture of mental illness in the homeless population, there are things that we in healthcare can do to improve the lives of the homeless mentally ill and get them the care that they need. All healthcare workers can push for policies that increase resources for community-based mental health services, as the CMHA intended. Clinicians can at free clinics or contact local organizations that work directly with the homeless populations and inquire about how they can help. Telemedicine allows for easy communication between primary care doctors and specialists and can be implemented to help primary care physicians take care of homeless patients with complex mental diseases like schizophrenia. Newer, long-acting injectable antipsychotics are available and are particularly useful for populations with limited capacity for compliance, including homeless people.
The history of deinstitutionalization is still being written, and we all can still be a part of the solution that visionaries like Tuke and Kennedy believed in.
is a medical student at the Pennsylvania State University College of Medicine, set to graduate in 2021. His professional interests include advocacy, global health, and disorders of the mind.