There Has Always Been a Thin Line Separating the United States’ Jails and its Mental Healthcare System

In recent decades, U.S. jails and prisons have grown overcrowded with people in dire need of mental healthcare services. Some estimates suggest nearly half of all incarcerated Americans suffer from mental illness. Incarcerated Americans are three times more likely than other adults to have recently experienced a severe mental health crisis. So many incarcerated people struggle with mental illness that jails and prisons actually comprise the U.S.’s largest providers of mental health care—a sobering figure that reveals huge gaps in the nation’s mental healthcare system.

Despite the overwhelming demand for mental healthcare services in American jails and prisons, most correctional institutions lack the ability to effectively treat mental health issues, as they do not have the proper staff, training, physical infrastructure, or budgets. This lack of care means that mentally ill Americans usually “just get worse and worse” in jail, according to psychiatrist Stuart Grassion. Often the manifestations of mental illness—which jailers tend to interpret and punish as misbehavior—results in individuals’ sentences being unfairly extended. The use of coercive punishment like solitary confinement on mentally ill prisoners only exacerbates the problem, according to Grassion’s decades of research. He writes, “It’s a tragedy—absolutely immoral—to see that happen to people.” Increasingly, it seems like the thin line separating American jails and prisons from the nation’s mental healthcare system is collapsing. 

In reality, however, the U.S. has a long, troubling history behind the overlap of jails and mental healthcare facilities. Situating the current crisis in the context of nineteenth-century American psychiatry reveals that there has always been a thin boundary between America’s carceral state and its mental healthcare systems. 

Noble, But Ill-fated Dreams

Until the mid-nineteenth century, the U.S. lacked formal medical facilities dedicated to treating mental illness. Before the 1830s, Americans who suffered from “insanity” were usually confined in jails and almshouses (shelters that provided housing for the poor) when their families could no longer look after them. Consequently, these correctional facilities were inundated with “inmates” who had committed no crime at all, but simply struggled with mental illness. Philadelphia’s Blockley Almshouse counted 1,588 people in 1848, with about half in the hospital and insane wards. The picture was just as grim in jails. After volunteering to teach a Sunday School class to imprisoned women in Boston jails during the 1830s, the famous health reformer Dorothea Dix encountered a group of mentally ill people jailed alongside violent inmates in deplorable, neglectful conditions. They had committed no crime but ended up in jail simply because Boston lacked enough beds in the local hospital to treat the city’s mentally ill.^[1]

By the 1830s, jails and almshouses were so inundated with mentally ill inmates that a new system of mental healthcare became necessary. Between the 1830s-50s, Dix worked with likeminded physicians and state officials to develop a more humane and effective mental healthcare system. These reformers believed that mental illness could be best handled by moving people out of carceral institutions into new, dedicated mental healthcare facilities called “asylums.”

As the name implies, asylums were meant to be sanctuaries where “insane” patients could be safely housed and humanely treated with “moral therapy,” then the cutting edge of psychiatry. Treatment involved changing the environment in which the mentally ill lived, which was thought to influence sanity—so it seemed only natural to move individuals out of dirty, overcrowded, dangerous jails and almshouses. Doctors’ goal was to cure the mentally ill and return them to families and communities, not lock patients up indefinitely. 

This noble dream was short-lived. Most states founded public asylums between 1830 and 1870, but moral therapy did not usually improve individuals’ mental health. In the wake of the Civil War, many states faced severe budget shortfalls. Frustrated legislatures gradually reduced financial support for asylums, which seemed like bad investments. Despite the lack of funding, however, demands on asylums increased. So over time, as more patients entered these facilities, “cure” rates plummeted. What began as a well-intentioned experiment in new forms of mental healthcare soon devolved into the practice of warehousing the mentally ill, as it had before the 1830s. Only now, instead of being locked up in jails and almshouses, mentally ill Americans were incarcerated in asylums—same outcome, different venue. 

By 1900, asylums transformed into overcrowded custodial institutions. After arriving, most patients never got discharged. According to historian Gerald Grob, “the mental hospital became the very antithesis of the ideals and hopes of its first founders and early leaders.”^[2] These institutions, which were meant to spare mentally ill individuals from the cruel treatment and dangerous conditions in jails ultimately become more like prisons than not. One critic surmised in 1880 that “it is fair to say that in the present state of psychiatry in America, to be pronounced insane by physicians, by a judge, or by a jury, means imprisonment for months, for years, or for life.”^[3] There were so many people crammed into Louisiana’s lone state mental asylum at Jackson that the city of New Orleans opened a second facility, converting a jail ward into a makeshift asylum. This was an ironic solution, considering that asylums had failed to solve the problems of locking up the mentally ill. Critics did not mince words, dubbing this facility a “lock-up,” “calaboose,” and “man-kennel.” Calling the place an “asylum,” wrote one enraged doctor, was an “outrage to humanity and the English language.”^[4] By 1900, overcrowding meant that most mental asylums were “nothing more than a prison for insane persons,” according to historian Grob.^[5]

Patients at most late-nineteenth century asylums were drugged or physically abused by staff to keep them pliant. At New York’s State Lunatic Asylum at Utica, one of the U.S.’s flagship asylums with renowned doctors at the helm, staff often locked patients into a device called the “Utica crib.” Patients subjected to this cruelty were forced to lie prone, unable to stand, for extended durations as their mental and physical states atrophied. One woman testified to the state legislature that she was “cribbed” for two or three weeks, resulting in a dissociative state. Strapped for funds, asylums like Utica were short on trained doctors, and poorly trained attendants often used beatings to control patients. Such treatment was all too similar to that endured by incarcerated mentally ill Americans today, more than a century later. 

The End of the Asylum

The deplorable conditions in mental asylums ultimately helped spark the deinstitutionalization movement of the mid-20th century, which sought to abolish the asylums. Proponents of deinstitutionalization charged that civil rights abuses, many stemming from overcrowding and underfunding, were rampant in mental hospitals, and that the coercive psychiatry practiced in the hospitals was rarely therapeutically effective for patients in any case. As one prominent critic, the “anti-psychiatrist” Thomas S. Szasz, put it in 1970, “Institutional psychiatry is, itself, an abuse.”  He went on to compare mental asylums to the barbarity of the Spanish Inquisition—a charge echoed over a century prior by Robert Fuller, whose 1833 expose laid bare abuses he suffered in Boston’s McLean Asylum. 

A long time in the making, the deinstitutionalization movement of the 1960s and ‘70s was bolstered by the findings of historians like Michel Foucault and David J. Rothman, whose research challenged the noble intentions of American and European creators of the asylum. Scrutinizing the antebellum origins of American asylums, Rothman argued in 1971 that the institutions were created by middle-class white reformers to enforce their social values on the “socially deviant,” as opposed to helping the mentally ill. Meanwhile, new medical innovations, like the discovery of the first effective anti-psychotic drug, Thorazine, in 1954, paved the way for pragmatic alternatives to institutional psychiatric care. For the first time, certain forms of mental illness could be more effectively treated with outpatient care than in inpatient facilities.  A series of court decisions hastened the deinstitutionalization movement in the 1960s and ‘70s. Perhaps even more important in the decline of the asylum, in 1965, newly created Medicaid incentivized states to move mentally ill patients out of large, centralized state psychiatric institutions into smaller community health facilities, where patients had more ready access to loved ones and where treatment was supposedly less coercive.

Although well-intentioned, deinstitutionalization ultimately worsened America’s mental healthcare. When state mental institutions closed down, few effective solutions existed in their stead to serve the needs of Americans suffering from certain forms of mental illness. For example, Clozopine, the first antipsychotic drug approved by the FDA to treat schizophrenia, did not hit pharmacy shelves until 1990, leaving many individuals with schizophrenia without decent medical care for decades. Meanwhile, states and the federal government slowly pulled funding away from community-based mental healthcare, and today such facilities are severely underfunded and overcrowded, much like asylums in the late 1800s. Now that fewer dedicated mental healthcare facilities are available to serve the severely mentally ill, jails and prisons have become the new mental asylums. 

Rather than rectifying the state-sanctioned abuse of mentally ill people in America, deinstitutionalization ended up causing many people with mental illness to collect in jails and prisons because there were fewer dedicated mental health wards. As one group of alarmed experts observed a decade ago, “we have now returned to the conditions of the 1840s by putting large numbers of mentally ill persons back into jails and prisons.” Thus, “deinstitutionalization,” according to another expert, “has been a psychiatric Titanic,” an unintended disaster of epic proportions that has only left mentally ill Americans even more exposed to state-sanctioned abused, this time in jails rather than asylums. 

Historically, the line between incarceration and mental healthcare has always been blurry. The problem of incarcerating the mentally ill has waxed and waned in American history, and while it is especially pronounced in the present moment, it has a much longer history than most Americans realize. This history teaches us that if we are to solve America’s long-standing problem of punishing the mentally ill by locking them away in jails and prisons, we need to realize the scope of the problem, which is centuries in the making. Whether jails or asylums, the mentally ill have long been locked up in America, and we need innovative solutions to make a clean break from this tragic history. 

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Featured image: Stereoscope (mid-nineteenth century) of New York’s State Lunatic Asylum at Utica. Thousands of mentally ill New Yorkers were committed to the asylum during the nineteenth and early twentieth centuries. Image courtesy The Asylum Project, http://www.asylumprojects.org/index.php/File:Utica_Stereoview1.jpg.

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^[1] Gerald N. Grob, Mental Institutions in America: Social Policy to 1875 (New York: The Free Press, 1973), 94n11, 103-5.

^[2] Grob, Mental Institutions in America, 175. 

^[3] Grob, Mental Institutions in America, 1, quoting E. C. Seguin in 1880. 

^[4] Grob, Mental Institutions in America, 365.

^[5] Grob, Mental Institutions in America, 1.