Back in the day when I was a sad little human with sad little “coping mechanisms,” I used to virtually hang around various mental health fora. This was in the days of Xanga and, to a lesser extent, Livejournal, when online communities were organic and, like a lot of organic material, subject to rot. I used to visit these sites to see what other people experienced and to gauge myself against the rest of the crowd — it was like the world’s lonliest gameshow entitled ✨ How! Sick! Are! You? ✨ wherein I was the only contestant and the prize was everything sucks.
Anyway, during this time, I learned the shorthand term “the bin.”
“90 days bin free!” one person would post.
“Back in the bin >:( “ another would share.
Finally, some dingus who wasn’t in the know (a group which included me, but I would never actually ask)requested clarification. The bin?
The loony bin. It means the loony bin. It means being institutionalized.
I didn’t know this because I was never institutionalized. And not for lack of trying! The only reason I was never put in the bin was because I was poor and American healthcare is a barren wasteland that will bleed you of all resources. I’m not alone in this if the dearth of low-cost mental health treatment facilities is any indication; with fewer than 200 public state mental hospitals in the entire country, there are a whole lot of people who could benefit from that level of intensive in-patient treatment just don't get it.
In fact, there are about the same number of publicly-funded state mental hospitals as there were 100 years ago, in spite of all the reasons you’d think there would be more — increased awareness and diagnosis, a population explosion, the invention of basically everything pertaining to medication. But no. If you’re poor and crazy, your options in the United States are very, very limited.
Public mental hospitals have long been viewed as dark, tragic places — which they definitely were and still are — but they’re also often the only resource for low-income and uninsured people. And uh…they don’t need to be horrifying trauma-factories? Like they didn’t get that way because they’re cursed? Or maybe they are cursed, but the curse if something like *waves wand* politico indiffico!
It wasn’t always this way. Though we, collectively, as people don’t have a great history with mental health institutions — “bedlam,” of course, is derived from Be thlehem Royal Hospital — we do have a history of having a lot more of them (and actually funding them).
Seeking Asylum
You may recall the “moral treatment” that was popular at the turn of the nineteenth century. During this time, instead of essentially jailing people (which had been pretty common and is also kind of how we do it today), individuals with demonstrated mental health issues (more on that in just a sec) might be placed in special wards designed to help them heal.
Penn State’s Patricia D’Antonio has a fantastic history of this time, so I’ll quote her:
“The moral treatment of the insane was built on the assumption that those suffering from mental illness could find their way to recovery and an eventual cure if treated kindly and in ways that appealed to the parts of their minds that remained rational.”
The most critical part about this shift in thought was the idea that treatment for mental health issues should be conducted in a neutral space, i.e., not at home. Prior to the 19th century, “insanity” of all sorts was managed by family members who were not at all equipped and rarely knew what to do, resulting in a real grab-bag of outcomes. The moral treatment insisted that these individuals be removed for healing and therapies (like chair spinning and stuff; talk therapy wasn’t really en vogue).
A lot of people who were running these places were actually really trying to do a good job and provide a kind service. Dr. Thomas Story Kirkbride, a bright young Quaker who created one of the actually-helpful, decent facilities, became a leader in the moral movement. His vision, called the “Kirkbride Plan” included clear boundaries, like a cap on patients (no more than 250) and a prescription for fresh air, sunshine, and mental stimulation.
Importantly, this plan specifically focused on providing good care for people, whether their families could afford it or not.
Kirkbride was adamant that public hospitals, specifically, should be readily available to ensure that the indigent may get quality treatment whether or not they can pay for it — and he wasn’t the only one.
”Reformers throughout the United States urged that the treatment available to those who could afford private care now be provided to poorer insane men and women,” writes D’Antonio, noting that “Dorothea Dix…travelled throughout the country in the 1850s and 1860s testifying in state after state about the plight of their mentally ill citizens and the cures that a newly created state asylum, built along the Kirkbride plan and practicing moral treatment, promised. By the 1870s virtually all states had one or more such asylums funded by state tax dollars.”
And that was a lot! A lot of places that people could go when they couldn’t afford other care!
So uh…what happened to this new, more caring, potentially even more inclusive mental health care approach, with a robust, Kirkbride hospital on every corner?
Money.
Yeah, it was money.
Psychiatric hospitals quickly became dumping grounds for people who had no business being there. Old folks who were just old. Women who were just poor. Orphaned teens. The hospitals became like a second-string jail, providing services that should have been provided other places but we not because of purse-string-tightening. This increase in population made it very difficult for nurses and doctors to provide care.
Then it got worse.
First it was the economic depression of 1893. Then it was the First World War, which sent home thousands of young men, traumatized and in need of medical care. Then it was the economic collapse that followed. Then it was the next World War. And then, and then, and then.
The nation’s public mental health hospitals were overrun with people who were physically ill — flu patients, those with TB and other incurable diseases — because there wasn’t room for them anywhere else. In a report published in the journal Missouri Medicine, Dr. Melissa A. Hensley summarizes that “large state institutions began as facilities where those with mental illness could come not only to receive treatment, but also to recover. By the end of the century, however, these hospitals had become custodial facilities. Public asylums housed large numbers of the mentally ill, but they were no longer providing innovative treatment, or in many cases, any treatment at all.”
What did state and federal government decision-makers do? Did they stand up additional hospitals and services for low-income folks in need of residential, non-psychiatric care? Of course not. They just let these state hospitals — an absolutely necessary lifeline — become an absolute morass.
In the end, the perception of mental health hospitals and the people who needed them waned so much that the funding almost entirely dried up, leading to a decidedly un-Kirkbride-like experience. Funding for public hospitals for mental illness were whittled away, year by year, as the population increased and staff made do with less and less money, and fewer and fewer staff members. This went on for, oh, the last 120 years or so. And boy howdy, it’s still happening!
A 2012 report from NAMI calls these persistent cuts “a national crisis.”
Between 2009 and 2011, states cumulatively cut more than $1.8 billion from their budgets for services for children and adults living with mental illness. The magnitude of these cuts in a number of states is staggering. California cut $587.4 million during this period, New York $132 million and Illinois $113.7 million.
You probably thought this “ignoring it and defunding it and hoping the problem will just go away” plan was sure to work out, right? Because that’s how it always goes?
No, of course not. You know better. You know what happened. You can see it literally all around you. The Treatment Advocacy Center, a non-profit that works to expand state hospitals, explains that “from their historic peak in 1955, the number of state hospital beds in the United States had plummeted almost 97% by 2016.” Additionally, “by 2014, 10 times more people with serious mental illness were in prisons and jails than in state mental hospitals, a circumstance widely attributed to the shortage of beds to provide timely treatment.”
There are so few beds now for people who can’t afford to pay for private mental health care (*points at self*) that we’re rapidly increasing the cost of not treating it. A Kaiser Family Foundation report found that “State government spends more money dealing with the burdens of substance abuse than on its prevention or treatment. The average cost to treat a substance-addicted individual is $1,346 vs. a $17,300 cost to society not to treat.”
And yet, instead of aggressively funding out state mental hospitals — hiring doctors and nurses who aren’t burnt out and paying them enough to live and thrive, updating facilities to treat an array of issues, and ensuring there are proper oversights in place and in practice — we gut their funding when they’re failing and fail to make any kind of additional services available to patients.
So, you know, it doesn’t really seem that complicated. The times when our public mental health institutions were doing the bulk of their progressing and treating the most people was when they had ample funding. Seems weird that we shouldn’t just…do that, then, right? Because creating safe, trauma-informed, culturally-competent, care for low-income people would 100000% improve the state of our states? Because most states definitely have the money to do it?
You don’t need to take my word for it. Here’s Dr. Kirkbride again, bringing it home.
“Those who frame the legislative bills providing for these institutions, frequently have it in their power to do much towards deciding their future character and usefulness, by a careful attention to the nature of the acts which are passed, and by insisting upon a judicious selection of the men who are to choose the site, decide upon the plan, superintend the erection of the building, and control its subsequent management.
As great power is commonly placed in the hands of these individuals, it will readily be understood how important it is that they should be men of high character, strict integrity, active benevolence, and of business habits. They should be willing fully to inform themselves of the character and responsibility of the high trust confided to them, and should avoid hastily taking any step which might mar to a greater or less extent, the usefulness of the institution as long as it may exist.”
One last note….
This is not to say that the public state mental hospital was a gift to humanity, ro even that, in some cases, it didn’t do more harm than good. Naturally, the idea of who had a “rational” mind was super-subjective. It left room for The Yellow Wallpaper-esque constriction, confinement, and control; unnecessary operations or interventions rooted in eugenics; and forced sterilization, among other barbaric “treatments.” At a time when most people didn’t have rights or bodily autonomy or, like, human dignity, the proliferation of public hospitals made it much easier for people to foist any number of members onto the state.
This lack of clear definition, along with obsequiousness to the hallowed status of doctors, are just a few of the reasons why the locations which were initially designed to be places of respite — asylums — turned into gaping hellmaws of trauma and tragedy. Entire groups of Indigenous people were certified “insane” so that they could be contained in state hospitals, their identities forcibly erased.
But again, that wasn’t because mental health hospitals HAD to be the seventh circle of hell. It was because the law and the culture in the United States permitted the use of these locations as holding grounds for people who were undesirable, inconvenient, or icky.
And, as you know by now, dear reader, these lovely, airy places were not open to everyone. The first mental institution for enslaved individuals who had recently been freed wasn’t opened until 1870. The Central Lunatic Asylum for Colored Insane, later renamed the Central State Hospital, was the only place where Black patients could get treatment without being relegated to a less-kindly segregated area of one of the other state hospitals. But that didn’t make it better!
Dr. King Davis, writing about the segregation of mental health institutions, noted that both the segregated wards of these hospitals Central State itself “were often underfunded, overcrowded, unrepaired, understaffed, and dependent on uncompensated patient labor often masqueraded as effective treatment. Much of the care they provided was substandard as shown in a review of treatment records.”
Just wanted to make sure we got that in there. Because while opening more publicly-funded mental health institutions is absolutely critical, it’s also essential that we do it with a keen eye trained toward all the ways we’ve previously used these establishments to further our sexist, racist, classist, anti-immigrant, anti-Indigenous systems.