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Why were mental hospitals closed in the United States?
The closure of state-run mental hospitals in the United States, a process known as deinstitutionalization, was not the result of a single event but rather a complex and decades-long convergence of scientific, social, legal, and economic forces. This movement, which began in the mid-1950s and accelerated through the 1980s, fundamentally reshaped mental healthcare in the nation, leading to both intended positive changes and devastating unintended consequences.
The primary factors that drove the closure of these institutions can be broken down into four key areas:
1. The Advent of Psychotropic Medications
The single most significant scientific catalyst for deinstitutionalization was the development of the first effective antipsychotic drugs. In 1954, Chlorpromazine (marketed as Thorazine) was introduced in the U.S. For the first time, a medication could reliably manage the severe symptoms of psychosis, such as hallucinations and delusions, that had previously made many individuals with schizophrenia and other severe mental illnesses seem unmanageable outside of a total institution.
The success of Thorazine and subsequent medications created a powerful new paradigm: it was now pharmacologically possible to treat patients in a community setting. Proponents argued that these drugs could “liberate” patients from the confines of asylums, allowing them to live more integrated and dignified lives.
2. A Shift in Social and Philosophical Ideals
By the mid-20th century, public and professional perceptions of state mental hospitals had soured dramatically. Several factors contributed to this change:
- Exposure of Horrific Conditions: Conscientious objectors who worked in state hospitals during World War II, along with investigative journalists and sociologists like Erving Goffman (author of Asylums), exposed the grim reality within these institutions. They were often severely overcrowded, underfunded, and understaffed, functioning more as custodial “warehouses for the unwanted” than as therapeutic centers. Reports of patient abuse, neglect, and the use of inhumane treatments like lobotomies and insulin shock therapy shocked the public conscience.
- The Civil Rights Movement: The broader social movements of the 1960s championed individual liberty and fought against segregation and discrimination. The principles of the Civil Rights Movement were extended to people with disabilities, including mental illness. Advocates argued that confining individuals in isolated institutions against their will was a violation of their basic human and civil rights. The guiding philosophy became treatment in the “least restrictive environment” possible.
3. Legal and Political Action
The shifting social ideals were codified into law through landmark political action and court rulings.
- The Community Mental Health Act of 1963: Championed by President John F. Kennedy, whose sister Rosemary had a developmental disability and underwent a lobotomy, this act was a pivotal piece of legislation. It aimed to replace the large, state-run institutions with a nationwide network of community-based mental health centers (CMHCs). The vision was to provide a comprehensive range of services—including outpatient care, emergency services, and partial hospitalization—that would allow people to receive treatment while remaining in their home communities.
- Key Court Rulings: A series of court cases established critical legal precedents that made it much more difficult for states to involuntarily commit individuals. The landmark Supreme Court case O’Connor v. Donaldson (1975) ruled that a state cannot constitutionally confine a non-dangerous individual who is capable of surviving safely in freedom by themselves or with the help of family and friends. This decision affirmed a right to liberty for people with mental illness and placed a higher burden of proof on the state for long-term institutionalization.
4. Economic Incentives
While the above factors provided the ideological and scientific justification, economic pressures provided a powerful motivation for states to close their hospitals.
- Cost of State Hospitals: Running massive, residential state hospitals was enormously expensive for state governments. Closing them offered the promise of significant budgetary savings.
- Shifting the Financial Burden: The creation of federal programs like Medicaid and Medicare in 1965 created a perverse financial incentive. These new programs would pay for care in general hospitals and nursing homes, and for outpatient services provided by the new CMHCs. However, they explicitly excluded payment for care in an “institution for mental diseases.” This meant that states could save money by closing their own hospitals and shifting the cost of care for the mentally ill onto the federal government by moving patients into federally subsidized settings or community programs.
The Consequences and Legacy
The vision of deinstitutionalization was a noble one: a robust, community-based system of care that would replace the inhumane asylum system. The reality, however, was a profound policy failure.
The most critical failure was that the money did not follow the patients. The Community Mental Health Centers envisioned by President Kennedy were never adequately funded by federal or state governments. As state hospitals closed their doors and discharged hundreds of thousands of patients, the community infrastructure to support them was not in place.
This led to a series of dire consequences that persist today:
- Homelessness: A significant portion of the chronically homeless population in the U.S. suffers from untreated serious mental illness.
- Criminalization: Without community support, many individuals with mental illness ended up in crisis and were arrested for minor offenses. This led to a phenomenon known as “transinstitutionalization,” where the mentally ill were moved from one institution (the hospital) to another (the jail or prison). Today, major correctional facilities like the Los Angeles County Jail and Rikers Island in New York function as the largest de facto mental health providers in the country.
- The “Revolving Door” Syndrome: Many patients became caught in a cycle of brief hospitalizations for acute crises, followed by discharge back to the community without sufficient support, leading to relapse and re-hospitalization.
- Burden on Families: Families were often left to become the primary caregivers for their loved ones, with little to no training or resources.
In summary, mental hospitals were closed due to a powerful combination of new antipsychotic drugs, a civil rights-era push for human dignity, landmark legislation and court rulings, and strong financial incentives for states. However, the failure to adequately fund and build the promised community-based alternative turned this well-intentioned policy into a national tragedy, the effects of which are still deeply felt in America’s healthcare and criminal justice systems.