Recent cases of violence by the mentally ill highlight the need to reconsider a long-maligned institution that now offers a promising solution.
A full caption appears at the end of the article. ELEANOR SHAKESPEAREBy David OshinskyJuly 21, 2023 10:56 am ET711
The ongoing saga of the severely mentally ill in America is stirring attention again in a sadly familiar way. In Los Angeles in early 2022, a 70-year-old nurse was murdered while waiting for a bus, and two days later a young graduate student was stabbed to death in an upscale furniture store where she worked. That same week in New York City, a 40-year-old financial analyst was pushed onto the subway tracks as a train was arriving, killing her instantly.
All three assaults, random and unprovoked, were committed by unsheltered homeless men with violent pasts and long histories of mental illness. In New York, the perpetrator had warned a psychiatrist during one of his many hospitalizations of his intention to commit that very crime.The death of Jordan Neely speaks volumes about the public’s fear of the aggressive and sometimes violent behavior of the mentally ill.
Then came the chance encounter this May that led to the death of Jordan Neely on a Manhattan-bound subway car. Homeless and schizophrenic, Neely had spent most of his adult life in and out of emergency rooms, psychiatric wards and prison. He had 42 prior arrests, mostly for nuisance crimes, but also for assault. He’d recently pleaded guilty to punching an elderly woman in the face, fracturing her eye socket.
What happened in the moments leading up to his death is still in dispute. While a jury will decide whether another passenger’s chokehold on Neely was second-degree manslaughter or an act of self-defense, the attention the incident received speaks volumes about the public’s fear of the aggressive and sometimes violent behavior of the mentally ill. Most of all, Neely’s death highlights the failures of a mental health system that allows profoundly disturbed people to slip through the cracks.
On an average night, according to the U.S. Department of Housing and Urban Development, close to 600,000 people in the country will be homeless—a figure seen by many as an undercount. More than 40% will be “unsheltered,” or “living in places not suitable for human habitation,” and about 20% will be dealing with severe mental illness.
Experts sharply disagree about the contribution of homelessness to rising crime rates. Some emphasize that the most of these crimes are low-level victimless offenses, such as loitering or public urination. But others note the disproportionately high level of all crimes, including assaults and homicides, committed by those battling homelessness and mental issues simultaneously.
Had Jordan Neely and the others been born a generation or two earlier, they probably would not have wound up on the streets. There was an alternative back then: state psychiatric hospitals, popularly known as asylums. 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.The very term ‘asylum’ implies refuge for those in distress.
Asylums were created for humane ends. The very term implies refuge for those in distress. The idea was to separate the insane, who were innocently afflicted, from the criminals and prostitutes who were then commonly referred to as the “unworthy poor.” Asylums were popular because they provided treatment in isolated settings, far from temptation, while relieving families of their most burdensome members.
But “insanity” in these years cast a very wide net. A typical asylum included patients who were suffering from alcoholism, dementia, depression and epilepsy, as well as such now defunct diagnoses as “lunacy” and “melancholia.” The usual stay was marked in years, not months, as evidenced by the rows of crosses in asylum graveyards.
Over time, the number of institutionalized patients far outpaced the state’s willingness to support them. Funding and oversight disappeared. And this, in turn, produced a flood of exposés—some embellished, others sadly true—portraying these institutions as torture chambers where icepick lobotomies, electric shock, sterilization and solitary confinement turned humans into zombies.
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.”President John F. Kennedy signs the Community Mental Health Act, October 1963. The law aimed to shift treatment of the mentally ill from asylums to local clinics, but the results were likened by one critic to ‘a psychiatric Titanic.’ PHOTO: BILL ALLEN/ASSOCIATED PRESS
In October 1963, President John F. Kennedy put his signature to the last bill he would ever sign—the Community Mental Health Act. It aimed to demolish the walled-off world of the asylum in favor of 1,500 local clinics where patients could receive the drugs and therapies they needed. Kennedy had a personal stake in the legislation: His sister, Rosemary, had undergone an experimental lobotomy that left her severely disabled. On paper, at least, deinstitutionalization seemed both more humane and more likely to succeed. Then reality set in.
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.”
A few voices had predicted as much. In 1973, a Wisconsin psychiatrist named Darold Treffert wrote an essay about the dangerous direction in which his profession was headed. His colleagues had become so fixated on guarding the patient’s civil liberties, he noted, that they had lost sight of the patient’s illness. What worried him was the full-throated endorsement of recent laws and court decisions that severely restricted involuntary commitments. What purpose was served by giving people who couldn’t take care of themselves the freedom to live as they wished? He titled his piece, “Dying With Their Rights On.”
Treffert was referring to cases like Lessard v. Schmidt (1972), where a federal court ruled that involuntary commitment must be limited to cases involving the “extreme likelihood” that someone “will do immediate harm to himself or others”—a very strict standard. Three years later, the Supreme Court tightened things further by asserting that authorities had been too cavalier in locking away the “harmless mentally ill.” In O’Connor v. Donaldson, it declared: “Mere public intolerance or animosity cannot constitutionally justify the deprivation of a person’s physical liberty.”Should we return to the asylum model for treating the mentally ill? Join the conversation below.
Enter Joyce Brown, a 40-year-old woman who went by the street name “Billie Boggs.” The year was 1987, and Brown was living atop a heating vent on New York’s tony Upper East Side. It was a tense time for the nation’s largest cities, with exploding crime rates, rampant crack addiction, the AIDS crisis and thousands of homeless people camping in parks, bus stations, subway tunnels and doorways. Under extreme pressure, New York’s Mayor Edward Koch authorized the involuntary commitment of those living unsheltered on the streets. Brown was the first to be confined.
Little was known about her beyond her struggles with heroin and a diagnosis of schizophrenia following her eviction from a New Jersey shelter. Brown was more of a nuisance than a threat to the neighborhood—stopping traffic, screaming at pedestrians, using the sidewalk as her toilet. Social workers who periodically visited her worried that she ate poorly, never bathed and lacked the clothing to handle New York’s brutal weather. Some viewed her as self-negligent to the point of being suicidal.
Taken to Bellevue Hospital, Brown was bathed, deloused and given antipsychotic drugs. Four psychiatrists confirmed the diagnosis of chronic schizophrenia. Bellevue contained a courtroom where patients could challenge their confinement before a state-appointed judge. Most were represented by a public defender, but the American Civil Liberties Union took on Brown’s case, claiming that her confinement violated federal court guidelines.
Ironically, Brown turned out to be her own best witness. Carefully medicated, she testified thoughtfully enough to convince the judge that the evidence before him was too ambiguous to merit the loss of her liberty. But he surely was conflicted, writing: “There must be some civilized alternatives other than involuntary hospitalization or the street.”Joyce Brown, whose involuntary commitment to New York’s Bellevue Hospital sparked a civil-rights lawsuit, speaks at Harvard Law School in 1988. PHOTO: CAROL FRANCAVILLA/ASSOCIATED PRESS
Unfortunately, there weren’t. An appeals court reversed the decision to free Brown, leading her to refuse all medication. Another trial was held to determine whether antipsychotic drugs could be forced upon her, and this time she prevailed. The city, weary of lawsuits, chose to discharge her rather than to appeal.
Brown became an instant celebrity. She traveled the TV talk show circuit as “the most famous homeless person in America” and even gave a lecture of sorts at Harvard Law School. “I like the streets, and I am entitled to live the way I want to live,” she explained. Offered a room at a “residential hotel,” she quickly returned to the life that she knew best, panhandling for drug money at the Port Authority Bus Terminal before fading from public view. She died in 2005 at age 58.
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.The enormous vacuum created by deinstitutionalization has been a calamity for both the mentally ill and society at large.
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.
In this massive system, the mentally ill are less likely to make bail, more likely to be repeat offenders and far more likely to be victimized by other inmates. Given the sheer numbers, maintaining order in these prisons and jails depends heavily on antipsychotic medication. It’s hard to imagine a worse environment for the safety, much less the treatment, of the mentally ill.
Meanwhile, state mental hospitals continue to shrink. Gone is the laundry list of afflictions that marked asylum life in the 1950s. The majority of the current patients are there “involuntarily”—people who have been judged a danger to themselves or to others, who have been found not guilty of a crime by reason of insanity, or who are being evaluated for their competency to stand trial. Because so many psychiatric beds have disappeared, the waiting period for admission can take months, which means that inmates languish in jail without having been convicted of a crime.
In the past decade, a growing number of scholars from across the ideological spectrum have suggested a return to asylums. Among them is Ezekiel Emanuel, a leading medical ethicist, who joined with two colleagues in 2015 to recommend the building of “safe, modern and humane” state institutions to end the revolving door of homelessness-hospitalization-prison that passes for policy today.Actress Louise Fletcher as the sadistic Nurse Ratched in the 1975 film ‘One Flew Over The Cuckoo’s Nest,’ starring Jack Nicholson (right). PHOTO: UNITED ARTISTS/GETTY IMAGES
The model they suggested is the Worcester Recovery Center in Massachusetts, a facility for 320 long-term patients with private rooms and “a recovery-inspired residential design.” Opened in 2012 on the grounds of a long-abandoned state asylum, it cost $300 million to complete, making it one of the most expensive non-road construction projects in the state’s history.
There is little doubt of the need for it, and the early signs, including surveys of recovery outcomes, are encouraging. Since the goal is to serve patients, rather than to warehouse them, the price can be steep. In 2015 Massachusetts spent $55,000 per prison inmate, with some additional costs for those with serious mental health issues. Meanwhile, the Worcester Recovery Center, with an annual budget of $60 million, spent close to four times that sum per patient. How this will play out in the long run, and how many other states will follow, remains to be seen.
The very word “asylum” brings shivers to those old enough to remember its abuses. It has a disturbing cultural legacy to confront in the sadistic Nurse Ratched of “One Flew Over the Cuckoo’s Nest.” Bringing it back in any form will face the twin obstacles of cost and image. But for the most vulnerable among us, who exist in a world of peril to themselves and to others, it is a far better option than the alternatives of homelessness and incarceration.
David Oshinsky directs the Division of Medical Humanities at NYU Langone Health. His books include “Bellevue: Three Centuries of Medicine and Mayhem at America’s Most Storied Hospital” and “Polio: An American Story,” which won the 2006 Pulitzer Prize for history.