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Lukas Metzner Honors 354 March 2019 A History of Mental Institutions and Criminality in The United States
Lukas Metzner Honors 354 March 2019 A History of Mental Institutions and Criminality in The United States
Honors 354
March 2019
It seems strange that insane asylums, originally devised as charitable rehabilitative religious
institutions in the United States, have gained such notoriety--depictions of asylums from Batman
or One Flew Over the Cuckoo’s Nest make them among the scariest settings in our cultural
imagination. These institutions have played dual roles of treatment as well as confinement for
patients, which have led to tension between providing help to people labeled as mentally
unsound and holding them in treatment without consent. The tenuous balance between
rehabilitation and punishment has defined the history of mental institutions in the United States.
This paper will look at the development of the defining legal, cultural, and political contexts of
this relationship, from the oldest mental institutions established in colonial America, to the
deinstitutionalization that has defined mental healthcare in the United States. Despite rhetoric
about mental care historically focusing on humanitarianism, its primary function has always
normalcy (Ben-Moshe 2014). As mental health care and incarceration developed, these two
institutions remained tied closely together as disciplinary power mechanisms. In the wave of
20th century deinstitutionalization, the line between the two was further dissolved as the
apparent “liberation” of institutionalized mental patients often led to their criminalization and
incarceration (Slate et al. 2013). Today, this connects to massive issues with incarceration of
mentally ill1 individuals, and racism within the criminal justice and healthcare systems. A
historical analysis on the conditions of mentally-related incarceration can help to inform us of the
place and forms that mental healthcare can take in an abolitionist future.
The history of institutionalization and confinement of the insane in Western society reaches back
before the existence of the United States, but the establishment of mental institutions in the US
coincided with the rise of new attitudes towards the treatment of mental disability. Michel
Foucault posits in History of Madness (2006) that the societal reactions towards madness in
Europe had shifted significantly from the Enlightenment to the Modern Age due to structural
changes in the ways deviance was defined and treated. As capitalism came to shape the structure
of society, those who were unable or unwilling to fit the norms of labor production began to be
seen as deviants who needed to be either reconditioned or removed. Because they were not
productive, they were often eliminated, through laws such as “an act of 1575 covering both ‘the
punishment of vagabonds and relief of the poor’” through confinement in “houses of correction”
(Foucault 43). As Jean Khalfa summarizes in his introduction to the English translation of
History of Madness, the “classical experience” of madness in the seventeenth and eighteenth
centuries was defined by confinement (xvii). Insanity was seen as the antithesis of a structured,
rational, capitalist society, so society’s reaction was to lock up the insane along with other social
deviants, so that they would not taint “normal” society. If they could not be reconditioned, at
1
As this paper will discuss, the term “mentally ill” is itself problematic: it carries implications of deviance
and inferiority and can justify unneeded or unwanted treatment. When I refer to “the mentally ill” or “the
mad” in this paper, I refer to those who have been given this label, with or without their consent.
The punishing conditions of confinement for those labeled as “mad” arose not only from an
intent to punish or reform, they also came about as a kind of sorting mechanism to keep out
people not desperate enough to endure them. This meant that the mad were funnelled into
horrific conditions as a direct result of their inability to provide labor. Ben-Moshe argues that
institutions meant to care for the mentally disabled have always been contradictory and abusive
(Ben-Moshe 2014). This came to be in part because of underlying assumptions that people would
try to manipulate and abuse charity. A precursor to the mental institution was the almshouse,
which was meant to provide for people absolutely unable to care for themselves. However,
because they were intended as places of charity, they attempted to sort out “unworthy poor,” who
were able but unwilling to work, by making conditions “sufficiently inhumane and abusive to
motivate anyone who could work to do so” (Ben-Moshe 2014, 4). While these almshouses were
not incarceratory in the modern sense, economic conditions and new laws against vagrancy and
begging made them effectively the only outcome for poor, mentally disabled people. They were
forced into miserable confinement essentially as a consequence of their inability to fit the norm
of labor production, and were not institutionally differentiated from other deviants like petty
Confinement of the mentally disabled in Europe began as a process tied closely to criminal
punishment, with a primary function to discourage unusual behavior and ways of being and to
protect the rest of society. But a change began to take place around the end of the eighteenth
century along with the American and French revolutions. Foucault notes that this shift saw
madness, which had previously been associated with poverty and “unreason”, become
differentiated as a scientific and medical phenomenon, which defined its treatment in the modern
age. What changed was “not the inhuman rigour with which the mad were treated, but the
obviousness of confinement” (Foucault 2006, 417). It was the beginning of a humanitarian and
religious push for treatment over simple confinement for mental patients, also bolstered by a new
confidence in modern scientific medicine to master the mind. This attempt to “liberate” the
mentally disabled forms a historical backdrop as the first asylums were founded in the US based
off existing European models (Ben-Moshe 2014, 3). The modern approach to mental disability
was defined by specialization and “liberation”, but the freedom of mental patients was never
truly realized. A new political rationality held the belief that “under the right conditions imposed
from above, degenerate, disabled, criminalistic, or uncivilized peoples can be brought ‘up’ to
normative standards” (6). This did not mean that the mentally disabled became accepted, but
The state-run insane asylum and its legal foundation were born in the U.S in the early nineteenth
century: four privately funded asylums were opened in the northeastern U.S. between 1817 and
1825, “and the widespread establishment of state-run mental institutions soon followed” (Testa
2010, 32). Two legal principles legitimated the ability of the state to confine the mentally ill. One
was parens patriae, meaning “parent of the fatherland,” which assigns to the government a
responsibility to intervene on behalf of citizens who cannot act in their own best interest. A
second legal principle, police power, requires a state to protect the interests of its citizens by
regulating behavior, with force if necessary (Testa 2010). A major motivating factor of the
establishment of state asylums was an increase in public concerns about crime (Ben-Moshe
2014). Disciplinary institutions such as prisons and hospitals were seen as the remedy for these
issues, due to the belief that these places could “create an environment that exemplified the
principles of a well-ordered society and thereby cure inmates of insanity, deficiency, and
deviancy…. By codifying madness as both illness and danger, psychiatry gained legitimacy”
(10).
While the establishment of mental institutions coincided with the scientific delineation of mental
illness from other forms of deviancy and sickness, it was still tied socially to crime and prisons.
Up to that point, mental illness was often seen as a moral flaw, but now there was a new idea that
people could be exempt from blame for their own actions due to mental conditions. However, the
way that treatment was carried out resembled criminal punishment. Mental patients’ access to
rights and freedom were limited, as “the societal view in America was that persons with mental
illness lacked the capacity to make decisions…. [thus] all [asylum] admissions were involuntary”
(Testa 2010, 32). Patients deemed insane and dangerous were not technically criminals, but they
faced similar conditions and treatment tactics. As mental hospitals became places for treatment
surveillance of the mentally ill. Psychiatrists were believed to have the knowledge and expertise
to not just diagnose but even involuntarily commit anyone deemed mentally ill. In this sense
their normalizing power was equivalent to that of the judge and jury in criminal cases. And
although mental commitment was never said to be punitive in the same sense that prison was, it
took on all the characteristics of a carceral institution, which surveils, disciplines, and normalizes
its inmates. Much like incarceration, it confined individuals and held them up to a particular
standard of normalcy. Where criminals were surveilled and conditioned in prisons to become
upstanding members of society, mental patients underwent similar processes under the gazes of
psychiatrists in an effort to make them “normal”. Under the surface, prisons and mental
institutions performed similar normalizing disciplinary functions in society, and both formed
important parts of what Foucault called the “carceral archipelago” in Discipline and Punish
(1995, 297): institutions like residential schools and hospitals which used surveillance-based
Like prisons, mental institutions diminished the personhood of those inside them and relegated
them to an objectified lower status. In Asylums, Erving Goffman (1961) characterizes both
prisons and asylums as “total institutions” which control every aspect of the inmate’s life and
movement. One characteristic of such institutions is that they “defile precisely those actions that
in civil society have the role of attesting to the actor and those in his presence that he has some
command over his world--that he is a person with ‘adult’ self-determination, autonomy, and
freedom of action” (Goffman 1961, 43). He notes that in mental institutions, patients’ “personal
inefficacy” is established by the institution, for example, when their speech is often ignored.
Overseers only acknowledge physical expressions from and interactions with the patients, which
is one way of degrading the autonomy of the patient (45). Through different tactics, people in
both asylums and prisons undergo rituals that destroy the individual’s social personhood.
Similarly to prisons, institutionalization in asylums for mental patients could result in civil death,
the loss of the civil rights that constitute legal personhood. Though voting rights were not
revoked like they were for felons, long periods of institutionalization could mean loss of custody
and property rights. The story of Elizabeth Packard is one example. In 1860, she was put in an
asylum by her clergyman husband as punishment for exploring outside of her Presbyterian faith.
After a three year commitment, she returned home to find that she had lost her property and
custody of her children (Packard 1867). Ms. Packard was an intelligent and motivated individual
who won back her rights after filing a civil suit, but not all asylum patients were so fortunate.
Due to long periods of isolation and inability to live their civil lives, mental patients ended up in
a deprived condition of civil death similar to that of convicts. Confinement would “deprive
[them] of the right to vote, to sit as a juror, to bear arms, to marry and hold office, because [their]
physical conditions were such that [they] could do none of these things” (Dayan 2013, 56-57).
The practice of isolation was inspired by the Puritanical belief that isolation led to spiritual
cleansing, but we now know that long periods of confinement result in misery and deterioration
even in mentally healthy individuals. For those with preexisting mental issues, confinement was
a “receptacle for imperfect creatures whose civil disease justified containment” (63). Even
though the legal status of asylum patients was not diminished like that of felons, they were
relegated to a state of de facto civil death due to their confinement in civil institutions which
limited their freedom of movement and ability to live a civil life. Despite the efforts of Packard
and other reformers, commitment to mental institutions reached a peak of 559,000 inpatients in
Along with the Civil Rights movement in the 1960’s, deinstitutionalization began as advocates
began to push for “both a psychiatric finding of ‘mental illness’ and a legal finding of ‘danger to
self or others’ in order to hospitalize or treat a person against her will” (Ward 2014, 258). This
was also closely tied to the Due Process movement of that decade, which pushed for legal
expansion of the rights of criminal defendants through cases like In re Gault, which confirmed
that juvenile defendants should have the same due process protections as adults. Two landmark
Supreme Court cases in the movement against involuntary mental commitment were Lessing v.
Schmidt a nd O’Connor v. Donaldson (Ward 2014). Lessing saw a Wisconsin woman named
Alberta Lessing protest a court decision to commit her to an asylum on grounds that she was a
danger to herself. The court agreed that she was not given due process before being examined by
police and psychiatrists, and rejected the argument of parens patriae in favor of the defendant’s
right to due process (Ward 2014). In the latter case Kenneth Donaldson, who had been diagnosed
with paranoid schizophrenia, was held involuntarily in a Florida asylum for fifteen years despite
multiple appeals was awarded his freedom and damages by the court. Evidence showed that he
was never dangerous to himself or others, and could support himself independently (Ward 2014).
Following these decisions, the grounds for involuntary commitment in the United States
narrowed drastically. That these cases were grounded in the Due Process revolution, which had
expanded the rights of criminal defendants, shows how involuntary commitment was
inextricably tied to criminal procedure, though the legal justification for state custody was
different.
Advocates for deinstitutionalization pushed for mental illness to be decoupled from the carceral
techniques the United States had utilized for treatment in the previous two centuries. In an era of
mental institutions were increasingly seen as overcrowded, unsanitary, and badly run, and public
concern arose about violations of the rights of mentally ill people. There was a push away from
psychiatric commitment and towards community-based mental health care. By the 1990’s the
number of inpatient psychiatric patients in the United States had dropped to 30,000, down from a
neoliberalism began to co-opt deinstitutionalization for its own goals, moving the focus of the
movement away from patient rights and toward economic efficiency. While forces like the Due
Process revolution and anti-psychiatry began to advocate for deinstitutionalization, it was the
economic arguments behind cuts for social safety nets that drove the movement the furthest
(Fakhoury 2007) (Gilmore 1999) (Testa 2010). The 1960’s saw the introduction of Medicaid and
Medicare, which transferred some expenses onto taxpayers, who began to believe that the cost
“was not worth the limited benefit that could be seen as a result of institutionalization” (Testa
2010, 33). As it progressed into the 1970’s, rising fiscally conservative views on public spending
held that “deinstitutionalization should go beyond replacing asylums, and should promote care
with as little institutional input as possible, preferring self-help to any professional support,
hospitalization to hospitals” (Fakhoury 2007, 313). R.W. Gilmore (1999) sees this period in the
early 1970’s as the dismantling of the Keynesianism that had defined the post-war golden age of
American capitalism. According to Gilmore, Keynesianism was defined by a “central logic that
full employment of resources enhances rather than impedes the production of new wealth” and
thus “provided workers with protections against calamity and opportunities for advancement”
(1999, 177). But during the economic crisis of the 70’s, capital moved its investments away from
the “social wage” and reduced its tax contributions, dismantling some of the welfare system,
which supported mental institutions. As the government lost tax revenue from large companies,
unpopular mental asylums were among the first institutions to go, under the veil of humanistic
reform. Ken Kesey’s 1962 novel One Flew Over the Cuckoo’s Nest and its 1975 film adaptation
are examples of the changing image of mental institutions as cruel and oppressive in the
make it more popular. But as would later be seen, the neoliberal economic drivers behind
deinstitutionalization meant that the rights of mental patients were no longer its main goal. This
also led to a lack of alternative sources of care or support for people who would have been
committed, which would have been prioritized if patient rights had really been the force behind
deinstitutionalization. Many of these people were left with nowhere to go, and have arguably
suffered more after deinstitutionalization as they have been redirected to the criminal justice
Immediately following the dismantling of mental institutions and other welfare mechanisms in
the economic crises of the 70’s, the new directive of government “materialised as the integument
of the prison industrial complex,” as the US government could always maintain legitimacy as
long as it centered its ideology on defence. (Gilmore 1999, 178). Gilmore argues that the
legitimacy of state spending was easier to maintain when the narrative was about crime and
safety rather than caring for the mentally disabled. The late 1970’s were a time of great income
instability for many Americans, which led to economic anxiety (Jacobs & Hacker 2008). In
response, political rhetoric tended to focus on fear and danger, and the law and order that would
be used to fight it. Ronald Reagan famously said in 1978 that “inflation is as violent as a mugger,
as frightening as an armed robber, and as deadly as a hit man,” conflating two of the strongest
contemporary political talking points (The Economist 2008). This period marks the beginning of
a drastic rise in incarceration as anxieties about social upheaval and the recession were funnelled
into fear of crime (The Sentencing Project). The government cracked down on crime with
harsher policing and sentencing practices, and mass incarceration began as a cycle where the
state and the prison industrial complex reproduced and legitimated each other. Historically, there
is a statistical trend between the closing of mental institutions and the expansion of prisons (The
Sentencing Project) (Rembis 2014). This can be explained qualitatively by the concept of a
criminalization of madness: “As state hospitals emptied, and many closed their doors
permanently, both former patients and the newly mad increasingly found themselves alone and
on the street or holed up…. At the same time, [people] began fashioning policies and programs
designed to segregate, isolate, and in many cases criminalize behaviors that in earlier decades or
other settings may not have warranted legal or judicial intervention” (Rembis 2014, 144).
Demographic data shows that “as public psychiatric hospitals closed, arrest and crime rates
increased” (149). In the state of New York in 1973, there were 93,000 state hospital patients and
12,500 in prisons. By 2000, there were only 5,000 in those hospitals compared to 72,000
imprisoned (150). The numbers demonstrate a demographic shift from mental institutions into
prisons. As asylums were shut down, the criminal justice system and its prisons began to take on
This criminalization of undesirable populations in this time period hearkens back to black
convict labor of the Reconstruction era South and the incarceration of Native populations and
hoboes in the early development of Los Angeles (Davis 2006) (Hernandez 2017). In the South
after the Civil War, Black Codes criminalized simple behaviors like vagrancy and absence from
work, but were exclusively enforced on formerly enslaved black populations. Their state of being
was made illegal, and so “they were divested of their status as slaves in order to be accorded a
new status as criminals” (Davis 2006, 363). Criminalization of black life served the dual
purposes of labor exploitation and racial segregation. On the other side of the country, some of
the first laws passed in California “targeted Native peoples for arrest, incarceration, and forms of
convict labor” as drunk and vagrancy codes were selectively enforced against Native men, whose
culture and presence was seen as disruptive to the white settler colonial values of the new state
(Hernandez 2017, 36). The state responded similarly when poor white hobo laborers began to
flow seasonally into Los Angeles in the late 1800’s. The city’s “elites and authorities marshalled
‘tramps’ and ‘hobos’” in order to insulate their “idyllic community of middle-class white
families” (63). In these situations outsider populations were criminalized and eliminated through
the criminal justice system. As mental health institutions were dismantled in the United States
with the alleged goal of liberating the mentally ill, the criminal justice system came through to
replace their role of elimination through incarceration for many of the most vulnerable
The results of this institutional shift have been disastrous. Los Angeles County Jail, Rikers Island
Jail in New York, and Cook County Jail in Chicago are “the three largest inpatient psychiatric
facilities in the country… [each hold] more persons with mental illnesses than any psychiatric
institution in the United States” (Rembis 2014, 139). Whereas mental institutions were
problematic due to medical ethics and lack of proper treatment, deinstitutionalization has led
many mentally ill people into a downward cycle of incarceration and recidivism: in 2005 “nearly
a quarter of state prisoners and jail inmates with a mental health problem, compared to a fifth of
those without, had served three or more prior incarcerations” (Ben-Moshe 2014, 13). Both
institutionalization and deinstitutionalization in mental healthcare in the United States have led to
similar outcomes for the mentally ill population, creating a sort of double bind likely to lead to
prison-like conditions either way. This population has been historically caught between two
mental institution and held there by the ignorance, arrogance, or personal pique of the staff.
“Nightmare #2 “envisions seriously disturbed (even if not ‘dangerous’) patients, helpless, unable
to feed, clothe, or care for themselves, and left to languish on the streets,” often ending up in
prison as carceral institutions have become the prevalent destination for such dispossessed
modern United States. More black men began to be diagnosed with schizophrenia just as both
black and mentally ill populations were increasingly incarcerated: “Beginning in the 1960’s
schizophrenia went from being a label applied largely to middle-class white housewives to being
a ‘violent social disease’ attributed primarily to black men” (Rembis 2014, 145). The labelling of
danger on both black men and schizophrenics targeted a population already especially vulnerable
to incarceration. The conflation of mental health and race in this case shows that both blackness
and mental illness were seen as indicators of violence and criminality. Today, both mentally ill
and black populations are severely overrepresented in prison populations (Sabol et al. 2007)
(James 2006). A 2015 report by the National Center for Health Statistics found that compared
with white men, hispanic and black men were less likely to report depression and anxiety.
Among those who did report these issues, a lower proportion of black and hispanic men sought
treatment for the disorders than white men (Blumberg 2015). This shows a disparity in access to
mental health treatment between ethnic groups in America. Race serves as a barrier to mental
health treatment, and people of color struggling with mental health are the most vulnerable to
Throughout the history of the United States, the mentally ill have been subjected to punitive and
institutions. In seeking possible alternatives for mental treatment, we can draw inspiration from
prison abolition movements. Abolitionism, which seeks to do away with all forms of
incarceration and replace them with alternative ways to prevent and remedy harm, is usually
focused on criminal justice and prison elimination (Davis 2006). Deinstitutionalization was, and
still is, associated with abolitionist movements and their rhetoric about liberation. However,
because the strongest drivers of deinstitutionalization in the 20th century were not abolitionist,
but neoliberal, the actual shift to community clinics that has taken place remains punitive. That is
because the strongest drivers of deinstitutionalization in the 20th century were not abolitionist,
but neoliberal. Rather than focusing on freedom and support for mental patients, the push shut
down mental institutions strove for “increased privatization of penalty and health care,” which
led to “not the decline of segregation [of the mentally ill], but its intensification through other
means” (Ben-Moshe et al. 2014, 268). Stripping down asylums and abandoning patients in need
of support in order to privatize healthcare was harmful for these people, even if closing down
mental institutions could have been a step in the direction of abolition. In efforts to apply
abolitionism to mental healthcare, it is important to work through both positive and negative
dismantled structures that confined the mentally ill, but there was no movement of positive
abolition, which involves building more free and equitable ways to prevent and remedy harm
without the oppressive functions of prisons. In the absence of support from positive abolitionist
movements, many mentally ill people who might have gone to asylums instead became homeless
or went to prison. Ben-Moshe (2014) argues that in order to advance the goal of abolition,
historical process (245). It should borrow more from the movement of anti-psychiatry, which
seeks to dismantle the hierarchies of power in healthcare and empower patients in matters of
their own mental health. Abolitionism in mental healthcare also means reframing concepts like
treatment, recovery a nd even disability, in a way that empowers people in matters of their mental
health. For example, a discussion of mental recovery implies a state of normality in mental
health, which sends a message that mental patients are in a way inferior to “normal” people,
of recovery could mean allowing individuals to take more agency in their own emotional and
mental lives. Even the term mentally ill, which I have used extensively in this essay, carries
alienating and patronizing connotations that suggest helplessness and inferiority in its objects.
Conceptual reframing works toward deconstruction of our ideas of disability and gives more
agency and independence to all people regardless of mental state. This independence does not
necessarily mean that mentally disabled people who want help should live without any; instead it
means giving them the support and autonomy to make decisions regarding their own care. In an
abolitionist future, this support can come from a better-integrated community. Abolitionism
already relies on community autonomy for many of its goals, such as community mediation in
community to mental health issues should be decided by people who actually understand and live
with the patients, rather than a rigid and hierarchical healthcare system.
The United States was founded around the time that Western society began to differentiate
mental illness from other kinds of social deviance and develop new methods for its treatment.
The establishment of early religious mental asylums signified a turn in objective from pure
confinement to the institutionalized normalization in treatment of the mentally ill. Whereas the
mentally ill had historically been cast out from “rational” society, they were now taken in by
powerful hierarchical institutions in an effort to reform their behavior, a process parallel, yet
separate from, the development of prisons to deal with crime. These oppressive asylums were
then dismantled in the 20th century, partially for the “liberation” of patients, but perhaps more so
because of a wide social and economic dismantling of social welfare institutions with the rise of
neoliberalism. With a lack of social support for the mentally ill, the criminal justice system again
stepped in as a measure to confine and control unsupported individuals deemed mentally unfit
for society. Overall, a historical pattern emerges where the mentally ill were lumped in with
criminals, then separated out but treated in parallel ways, and now are being pulled back into the
criminal justice system. This is not to suggest that history is a cycle that can only repeat itself.
incarceratory institutions as ways of dealing with both physical crime/harm and mental illness,
giving more support and autonomy to the people and communities that these issues affect most
severely.
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