AUGUST 24, 2020
IN 1967, psychiatrist Harry Brickman had high hopes for a new system to replace the abusive and dilapidated state mental hospitals.
Civil libertarians, ex-patient activists, and mental health practitioners were finally questioning the loose definition of “mental illness” and whether locking people away accomplished anything. With a radical vision of a better world, they campaigned to destroy the “Cuckoo’s Nest” asylums and transfer cost savings into communities. Brickman was a part of that revolution, and as the founding director of Los Angeles County’s Department of Mental Health he was in a position to do something meaningful when it came to long-term preventive care outside the walls.
With help from fiscal conservatives, they won the release of thousands of patients. But they got little else. The “community-based systems” were an underfunded joke and the money went elsewhere. California Governor Ronald Reagan quickly cut 2,600 jobs from the state Department of Mental Hygiene even as hospitals across the state were shuttered. In a 2009 interview, Brickman bitterly recalled Reagan’s broken promise:
[T]he handshake was that they would not close down the State Hospitals, until we in the community had an opportunity to develop halfway houses and transitional facilities for those with major mental illness. We shook hands, and, I think within a month, he began to close down the State Hospitals. […] The result of it is that they began to dump them on the streets.
Rather than getting at the root of social problems, Brickman’s Department of Mental Health struggled to provide basic survival resources. Similar stories would play out across the country as part of a general turn away from investment in public goods. That’s a core cause of today’s widespread patient homelessness and the misuse of jails as mental wards.
We cannot make this same mistake again, and must learn from history as we heed another stirring call for liberation. After this summer’s protests against police brutality and racism, America is listening to radical critiques of policing and prisons. A serious reexamination is underway that challenges the definitions of “crime” and the validity of penal approaches. Activist rallying cries like “defund the police” and “care not cages” draw on a prison abolitionist vision of a world where social problems are solved at their root, and lockup replaced with community solutions.
This is a bold and necessary step to undo a system that has wreaked havoc on lives, communities, and the moral fabric of the nation. Far too many people have been ensnared for reasons of class and race, and there is opportunity to rectify such injustice. Yet the failed revolution in mental health should serve as a warning. Apparent victories can be easily reversed and a hasty unraveling of institutions can turn disastrous.
As a sociologist who studies the United States’s shifting systems of social control at the intersection of welfare and penal policy, I want us to consider the parallels between the calls for prison abolition and the anti-asylum movement of the 1960s. These are different types of institutions, of course — the state hospitals were sites of both care and control, whereas penal facilities are only the latter — but there are similar difficulties in transforming institutional control systems to community integration. As a supporter of the Movement for Black Lives and campaigns to reallocate police and prison funds, I want to ensure that we avoid the mistakes of the past.
The vexed history of psychiatric deinstitutionalization provides an opportunity for reflection. What went wrong? How did it fall apart? And how can activists and policymakers learn from that history to better remake the criminal justice system today?
The first problem is that defunding campaigns can be co-opted as a form of “austerity measures” by those who simply want lower taxes. Whether through manipulation, incompetence, or bureaucratic loopholes, cuts may never manifest as reinvestment. Politicians like Reagan simply integrated the defunding of expensive hospitals into their broader dismantling of state services.
Why did psychiatric authorities and the government suddenly turn away from asylums in the 1960s? The story has multiple elements. New antipsychotic drugs such as Thorazine helped some patients move to community care. Revelations of abusive conditions shattered the hospital’s rehabilitative veneer. But the real driving factor, according to sociologist Andrew Scull, was the fiscal crisis of the welfare state.
The hospital system was hugely expensive for state governments, whose leaders in both parties searched for cheaper options. President Kennedy’s 1963 Community Mental Health Act promised to build a large network of community centers, and the introduction of Medicaid in 1965 and Supplemental Security Income in 1972 incentivized moving patients out of the wards. The Feds would pick up the tab for outpatient services.
The new system never fully materialized. Kennedy died before he could follow through with his act, and his successors built less than half of his expected community mental health centers. As a governor and then president, Reagan defaulted on his promise to grow the community system before asylum shut down. For many newly released patients, the meager SSI checks were hardly enough to thrive.
A second problem — which has profound implications for prison abolition — is that releasing people is easy but reintegration is far harder. The state has kicked vulnerable people to the streets before with zero help, and a similar lack of forethought could make de-incarceration a disaster.
Radical thinkers of the 1960s attacked the medical pretensions of the psychiatric asylum, questioned the definition of mental disorder, and doubted justifications for forced treatment in a liberal society. They offered a seductive but overly simplistic message of personal freedom that focused on “negative liberty” — that is, freedom from state intervention. This was not a helpful argument for long-term responsibility, and it also glossed over the real problems that liberated patients would soon have to face on their own.
Three key books, all published in 1961, argued that psychiatry was a pseudoscience and the asylum a form of unjust detention. Dissident psychiatrist Thomas Szasz’s The Myth of Mental Illness famously claimed that psychiatric diagnoses were less medical illnesses than catchall labels for political or social deviance. In sociology, Erving Goffman’s Asylums showed how the hospital environments assaulted patient identity and could drive anyone crazy. In philosophy, Michel Foucault’s Madness and Civilization defined psychiatric care as a “gigantic moral imprisonment” that replaced physical chains with insidious psychological control.
So what did release mean for such thinkers after the gates were unlocked? They never quite articulated a vision for that next step. Despite divergent intellectual positions, they were united in a desire to maximize individual liberty. Szasz was a libertarian who argued it was better to try psychotic people for crimes than hospitalize them since it afforded the dignity of trial. Goffman spent his career showing the ways that the social world both impinges and constructs the self. Foucault’s politics were mercurial, but he railed against any soft governance that reprogramed the human subject. None had interest in developing a robust welfare state. The socialist scholar Peter Sedgwick condemned them for providing ideological cover to the abandonment of vulnerable people. The civil liberties victories of hospital release never resulted in the “positive liberties” of housing, education, and health care that would enable people to live empowered lives.
The community system promised by Kennedy was ill equipped for the seriously disabled patients coming out of the hospital. Providers preferred to spend time with the depressed young person rather than the psychotic middle-aged person traumatized by 15 years in insolation. Talk therapists grew frustrated with patients who spoke either rarely or only in perpetual streams of consciousness and did not seem to get better. Treatment based on little more than medication injections became commonplace within for-profit psychiatric flophouses. Many were consigned to a life on the streets punctuated by brief emergency hospitalizations and then jail.
Disability activists demanded a right to quality voluntary care, but this was far harder to secure than “freedom.” People’s needs exceeded the capacity of these poorly funded public community services. Private insurance companies denied coverage to the severely disabled or failed to offer parity with physical health conditions. In the ultimate expression of “negative liberty” without “positive liberty,” many people found they could not access voluntary care at all. Only with a 72-hour hold or arrest might they actually get attention.
A last problem that is especially insidious: the oncoming failures may be attributed to botched reform ideas rather than the underfunding that botched them in the first place.
By the 1980s, critics of deinstitutionalization argued that a rising number of homeless people with psychiatric disabilities were “dying with their rights on.” At least the hospital system had served as housing and a site of basic survival resources. Increasingly the public perceived that asylum closure and the freed patients themselves were the cause of visible madness on the streets, instead of the gross inadequacies of the community care system.
Today there are an estimated 100,000-plus homeless people with serious psychiatric disabilities. Though the roots are structural — insufficient investment in public housing, constrained housing supply, and inadequate wages or benefits — the individuals take the blame. Similarly, the jailing of people with psychiatric disabilities is often attributed to deinstitutionalization itself, rather than the broken community system or inappropriate policing practices.
Family groups like the National Alliance on Mental Illness have rallied to return paternalistic legal powers to parents, so they could once again commit their adult children to treatment. In California today, cities like San Francisco have begun experiments to force people into guardianships at a lower legal threshold. These programs to reduce people’s rights have not gotten off the ground, however, because there are no hospital beds or housing to place them in. Thus some psychiatrists have issued a call to “Bring Back the Asylum,” taking us to a tragicomic full circle where institutional settings are cast as compassionate reform.
This history should not discourage the Defund the Police and prison abolition movement, but it should serve as a sobering marker. What will it take to bring people out of lockup into a world where prisons aren’t necessary? The cautionary tale of deinstitutionalization shows us how much work is required beyond merely defunding or closing abusive institutions. Terrible as they are, they serve important functions. The asylum and the prison both provide housing, food, and medical care — of generally abysmal quality, but sustenance nonetheless.
The United States is in a pandemic-driven fiscal crunch, so there may very well be cuts to both prisons and post-release services. If policymakers take the first away without replacing those functions, especially in a weak economy, it condemns a substantial portion of the decarcerated population to homelessness, dire poverty, lack of health care, and economic crimes of survival that could discredit future efforts at systemic change.
Abolitionists have struggled to correct public misinterpretation of slogans that seem to focus on the destructive — e.g., “defund the police” and “abolish prisons,” since they have always seen the reinvestment as equally important. In Angela Davis’s terms, abolition “is not primarily about dismantling, getting rid of, but it’s about re-envisioning. It’s about building anew.” In part because they seek a profoundly different world and see oppressive systems as interconnected, abolitionists can be skeptical of technocratic reforms. Mariame Kaba expresses this when she says that abolition is “an expansive vision and an expansive framework. It’s not a blueprint.” In a moment demanding concrete alternatives, however, rebuilding will require specificity and long-range planning.
Visions without blueprints can easily go astray, especially at highly unsettled political conjunctures. Consider again an echo from psychiatric history. Responding to a request for concrete alternatives to incarceration, the disability scholar-activist Liat Ben-Moshe demurs and notes, “One of the lessons from deinstitutionalization is that people just created a vision, even when things were not there. Even when people said ‘wait the community is not ready, how are people going to live in the community?’ It’s not ready. It’s never going to be ready. I mean, that is the lie of this. And this is why it’s really important to push in these moments of ‘not ready’ and ‘we don’t have answers.’” For Ben-Moshe, this bold vision and rapid movement was necessary to break through the belief that facility closure was impossible. Yet one could also argue that this liberation without adequate planning played into the hands of the Reagans of the world.
Today, many incarcerated people are ready to return to their lives. But for others, trauma from both their pasts and incarceration itself will mean that community living is complicated. Downplaying the complexity of rehabilitation and reintegration could appear politically expedient, but in the long run result in austerity measures and backlash. Thus one criticism of Michelle Alexander’s landmark The New Jim Crow is that it focuses on nonviolent drug offenders who could presumably reintegrate with ease, while ignoring the many prisoners with violent offenses who may require substantial and costly rehabilitation.
Deinstitutionalization shows what happens if we fail to invest in a system that can help the most needy or troubled. Fortunately, many abolitionists already emphasize a politics of care, restorative justice, and community building that the libertarian anti-asylum theorists lacked. Scholars like Ruth Wilson Gilmore note the need to build a world for people who have both been harmed and cause harm, with services in place across a range of circumstances. Far from pollyannas, these thinkers know that decriminalization and release simply bring complex social problems back into the open.
As the country reckons with the failures of mass incarceration and hyper-policing, activists and sympathetic lawmakers have a unique opportunity to implement abolitionist ideas. Deinstitutionalization’s history tells us that the easiest political compromise will be defunding without sufficient reinvestment. We can’t afford to repeat that mistake. If we are to move away from police and prisons, we must prioritize community investment and avoid settling for half-victories in the form of defunding and closure. We must embrace the difficult task of rehabilitating and reintegrating people, rather than downplaying or deferring to another day. And we must prepare for the inevitable problems with new systems, especially in a pandemic-ravaged economy, and have answers ready for those who would demand a return to penal enforcement.
We have the radical imagination — now is the time to turn visions into blueprints and viable policy.
Featured image: “Black Lives Matter – Century City Protest – June 6, 2020” by Brett Morrison is licensed under CC BY 2.0.