Flying the Cuckoo’s Nest

This chapter charts the multiple factors that spurred the deinstitutionalization of mental hospitals in the 1960s. In 1963, Congress passed the Community Mental Health Act, which funded the creation of community mental health centers and provided inpatient and outpatient care, partial hospitalization, emergency services, and public education. The creation of Medicare and Medicaid also caused many states to reduce their reliance on custodial mental hospitals. Meanwhile, anti-psychiatry texts like Ken Kesey’s One Flew over the Cuckoo’s Nest spurred anti-institutionalism and advocates filed successful lawsuits against involuntary commitment laws. Institutionalized people gained a plethora of civil liberties, further reducing the mental hospital population. The chapter explores these national changes at the local level at places such as the Philadelphia State Hospital. That institution released large numbers of people, many of whom faced hardship when they left the hospital. That trend reflected how changes in mental health law and policy did not guarantee that people could access medical and social services in their home communities.

Mental Hospitals and the Carceral State

This chapter explores how in the 1940s, mental hospitals comprised land, buildings, and workforces used by the states to feed and house hundreds of thousands of people. Conscientious objectors who did service work at mental hospitals in lieu of military conscription founded the National Mental Health Foundation. They also collaborated with journalists to craft exposés about concentration camp–like conditions in hospitals. The author and former patient Mary Jane Ward published her book The Snake Pit, in which she argued against the loss of freedom that people with mental illness experienced. Policy makers responded to this anti-institutionalism by implementing mental health reforms that made hospitals larger and more therapeutic, and kept involuntary commitments intact. These initiatives made up the early stages of deinstitutionalization.

Introduction

The introduction reviews the relevant histories of prisons, mental health policy, and the social welfare state. It highlights how recent scholarship has not connected the history of mental hospitals to the broader history of imprisonment. From Asylum to Prison frames historic mental hospitals as part of a broader carceral state and charts how the rise of mass incarceration shaped the closure of mental hospitals. Law and order politics served to criminalize mental health conditions and substance abuse. New prison construction in the 1980s took money away from mental health services and prisons absorbed many functions of the former mental health system. Finally, this history of deinstitutionalization offers lesson for people working to reduce mass incarceration in the twenty-first century United States. The introduction closes with a discussion of people-centered language and key terms such as institutions, carceral state, and mental illness.

Custodialism Reborn

By the end of the 1960s, anti-institutionalism had extended beyond mental health and bled into prison reform. This chapter tracks the rise and fall of efforts to find alternatives to prisons. In the late 1960s and early 1970s, changes in psychiatry, politics, and the law led to a deinstitutionalization in both mental health and corrections policy making. Not only did politicians and advocates look for alternatives to mental hospitals, they also sought alternatives to prisons. They expanded probation, parole, and furlough and created community corrections initiatives such as halfway houses and work-release programs. The number of people in prisons and jails fell, even during a time of increased policing. These reforms came under attack, however, as politicians depicted people in prison as dangerous criminals and ushered in harsh sentencing reforms. A law and order politics that relied on racial discrimination halted efforts to deinstitutionalize prisons. By the mid-1970s, after more than a decade of decline, new prison construction began and the number of imprisoned people nationwide rose. These changes had a devastating effect on individuals with mental health conditions. Many of them were caught in the web of this new era of mass incarceration.

Epilogue

The epilogue reflects on the contemporary crisis of mass incarceration in the United States, which has particularly affected people with mental health conditions and substance abuse disorders. It argues that today’s crisis is deeply rooted in the past history of mental health policy and offers a few main lessons for people working to make change. First, restrictive environments such as prisons and mental hospitals are inappropriate places to hold people on a mass scale. Second, it cautions people who are working to decarcerate prisons today. The history of deinstitutionalization proved that that cost-cutting cannot be the main reason for change, as it led to inadequate resources. People invested in prison reform should also be cautious that decarceration does not lead to new forms of restrictive environments, which happened during deinstitutionalization.

Unlocking the Doors

This chapter traces how the number of people in mental health institutions began to decline in the 1950s. It examines Pennsylvania as a case study and finds that riots and scandals at mental hospitals there put pressure on policy makers to move away from the institutional model of treatment. Public officials and psychiatrists planned new outpatient facilities and psychiatric care in community hospitals. At the same time, the state government managed social deviance through criminal justice reform as it expanded the police and prisons, which were rife with racial discrimination. The reforms focused on rehabilitation as psychiatrists devised smaller, treatment-oriented programs to try to curb behaviors such as juvenile delinquency. This chapter charts how on the one hand the 1950s ushered in an era of anti-institutionalism and deinstitutionalization in mental health. But, on the other hand, the decade also brought about an expansion of the criminal justice system.

Cruel Choices

This chapter explores how the 1980s hastened the shrinking of state mental health services and the rise of more punitive practices. President Ronald Reagan supported the continued downsizing of mental hospitals at both the state and federal levels. Homelessness and poverty became more immediate social concerns, since many states lacked adequate community-based mental health services. In Pennsylvania, Republican governor Dick Thornburgh closed mental hospitals and cut social welfare programs, strengthening neoliberalism in the state’s government. At the same time, he supported law and order policies and sentencing reforms, which targeted urban African American communities. The new prison construction siphoned money away from social welfare services. Many states even turned their abandoned mental institutions into prisons, and the chapter studies Farview State Hospital and the Retreat State Hospital as examples. In response, advocates at organizations such as the Mental Health Association of Southeastern Pennsylvania fought for the right to the least restrictive environment. They promoted adequate medical, mental health, and social services outside of institutions and worked in coalition with others to ethically close the Philadelphia State Hospital. This effort offered a model for alleviating the problems of deinstitutionalization.