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History Says NYC Mayor’s Mental Health Plan is Deeply Flawed

Involuntarily committing people with serious mental illness, however well intended, has long served to remove them from society instead of providing treatment.

Adams sees himself as having a “moral obligation” to revamp the city’s mental health care system and help the several thousand people estimated to live on New York City’s streets and subways. Yet, however well intentioned, his proposed policy resurrects a historical practice with a long, dark past. In fact, Adams’s plan is a direct echo of 19th-century ideas about “curing” mental illness, even if through forced medical treatment. Examining the past implementation of these ideas shows that involuntary hospitalization ended up functioning more as a way of removing those with mental illness from society than as a way of offering them medical treatment. Adams’s policy threatens to do the same.

Beginning in the 1870s, state hospitals, colloquially known as “lunatic asylums” or “mental hospitals,” became the primary site of mental health care in the United States.

Contrary to popular depictions of mental hospitals (e.g., “The Snake Pit,” 1946; “The Bell Jar,” 1963; “Girl, Interrupted,” 1994; etc.), asylum patient populations were not primarily composed of middle-class Anglo-American women experiencing nervous breakdowns.

Instead, state hospitals became a place to merely warehouse society’s most marginalized. They were filled disproportionately with immigrants, members of the working class and ethnic minorities. In fact, in the early 20th century, New York state legislators vocally advocated for more stringent restrictions to bar immigrants with mental illness from even entering the country.

As psychiatrists gradually realized that a true “cure” for mental illness probably did not exist, the overall medical aim of state hospitals shifted from treating patients’ illnesses to housing problematic “insane” individuals. Significant majorities of the institutionalized were involuntarily committed by families unable to care for them or after encounters with law enforcement. Many patients who were involuntarily committed spent the remainder of their lives institutionalized — subject to the wishes of the hospital staff who cared for them.

With large numbers of patients institutionalized for decades, the hospitalization of new patients produced severe overcrowding by the end of the 19th century. In response, state mental-health-care systems continually expanded their capacities. Asylum populations swelled from roughly 190,000 in 1910 until peaking at more than 550,000 people nationwide in the 1950s.

By the mid-20th century, these hospitals were underfunded, overcrowded, run-down and infamous for their gruesome conditions. In mid-century popular culture, the term “mental hospital” came to be synonymous with filth, grisly medical treatments (e.g., lobotomization, electroshock therapy, forced sterilization, etc.) and rampant patient abuse.

In the 1960s and 1970s, however, activists who called themselves “psychiatric survivors” led a broad cultural rejection of involuntary hospitalization and large institutional settings for treating mental illness. These activists argued that patients could be best treated in the least restrictive setting possible, ideally within their own home communities.