The History of Institutionalization in the US
- 4 days ago
- 4 min read
By Baylor Barnard
Rarely is there a case in history where a definitive inflection point can be so easily traced. One often-cited example is the life of Rosemary Kennedy. The younger sister of John F. Kennedy, Rosemary was born with intellectual disabilities, the full story of which is more than worth attention. In short, Joseph Kennedy put Rosemary through an extreme amount of medical experimentation to attempt to treat her. Eventually, the Kennedy patriarch was convinced that Rosemary might be helped by a lobotomy. This left her, “without the ability to talk, walk, and control her bodily functions” (1). Though that description is different depending on the source of information. Immediately after the procedure Rosemary, like many disabled people in the early part of the twentieth century, was hidden away from her family. It was not until the late 1950s that, at least according to Greg Rosalsky, that John F Kennedy learned of the state of his sister. Furthermore, it wasn’t until Joseph Kennedy suffered a stroke in the early 1960s that the secret was revealed to the entire family. Why tell this story? Well, John F Kennedy was elected President in 1960 and by the end of 1963, just before his own death, he signed into law the Community Mental Health Act (1). This is one of the most impactful pieces of legislation for both mental health care and the care of disabled individuals in the United States. Unfortunately, it is not for particularly good reasons.
The practice of institutionalizing the mentally ill or the disabled in the United States is older than the country itself (3). Though, as Michael Friedman of Columbia University puts it, there were no policies in Colonial America to do with mental health because it “was a concept that did not yet exist” (4). One of the Founding Fathers, Benjamin Rush, was an early voice in the study of Psychiatry. In fact, Rush is sometimes called “The Father of American Psychiatry” (2) and published, according to Psychiatry Online, the first textbook on the subject in the nation’s history (3). Now, since Rush was practicing in the end of the eighteenth and the early part of the nineteenth century, there is not a great deal of medical information that can be carried forward. As with many other cases of historical retrospect, it is easier to look back on these figures and appreciate their most positive qualities. Rush believed that more or less all illness originated in blood flow, and many of his treatments were based in the practice of purging his patients of various bodily fluids (3). Despite these now backwards practices, Rush also fought to create spaces in hospitals for the mentally ill, and recommended to doctors that they first approach their patients with respect. On the other hand, Rush then immediately escalated to straitjackets, keeping them from their preferred food, or a cold shower (3). By no means was Rush a perfect physician. That is not what is expected when looking back on early modern medicine and it is also not what can be found when looking at early modern American Institutionalization.
At the end of the 18th century, attitudes towards treatment of individuals with mental illness were shifting in America and Europe. Conditions for mentally ill or disabled individuals before this were horrific. Friedman writes of the various ways that communities cared for the mentally ill. Families paid for others to care for them, sold their labor to farmers, put them into poorhouses, chained them in jails or drove them out with violence (4). A major part of this shift was the concept of humane treatment, as well as the separation of different dependent populations into their own institutions rather than all within poorhouses (4). According to the Bureau of Justice Statistics, there were “about 20 mental asylums” in the United States by 1850 (6). Before the American Civil War, there were attempts to push asylums under the control of the state, and a law which would have provided a great deal of land to build these asylums passed Congress (this was vetoed by President Franklin Pierce).
As if it needs to be stated any further, State Hospitals in the United States were not provided the resources they needed to serve their constantly growing patient populations. According to Jeffrey Geller of Psychiatry Online, half of all hospital beds in 1955 were psychiatric beds (3). In short, conditions for these patients were horrific and patient populations were constantly on the rise. Still from Geller, in 1925 one hospital began the fiscal year with 2,523 patients. Throughout the year they gained approximately six hundred fifty more patients but only discharged about 430. As a result, they experienced a net gain of more than two hundred patients. Over ten years, this kind of patient population growth translates to nearly doubling the patient population (3). By 1955, the total population of individuals in state hospitals was 558,922 (5). In February of 1963, President Kennedy addressed Congress on the subject of funding for disabled and mentally ill people. He wanted the Community Mental Health Act to cut the institutionalized population of the United States, which was by then about six hundred thousand, in half. The measures passed through the Senate and the House with limited opposition (5).
There is a cruel irony to conditions which brought about the Community Mental Health Act and following that, its failure. The idea for the aforementioned Community Mental Health Act began with a confluence of ideas about the best possible solutions for psychiatric treatment. There had been advances in psychotropic medications, as well as a belief that some mental illnesses were the result of the environment. Finally, there was a push to shift people that were presently institutionalized into community mental health centers, thus the name of the legislation. Experts, both now and at the time, point out the unfortunate flaws for all of these ideas. Since these psychotropic drugs were still in their early stages, the dreams of their use were, at best, unrealistic. The belief that the previously mentioned, and only supposed, environmental causes of mental illness could be addressed, combined with an overly optimistic understanding of what could be done with community health centers, spelled doom for this solution (4). Which isn’t to say that it being attempted shouldn’t be applauded. Like many attempts at legislation of this kind, there was not enough money to fulfill its goals.
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