No Stupid Questions

There is a lot of nuance that gets lost in the discussion of asylums, particularly if you know about them primarily from fictional sources. Historically they were actually a great improvement over the model that existed up to the late 1800s. That model threw the mentally ill into a general prisoner population which included debtors, criminals, and anyone else deemed appropriate. There wasn't a keen understanding of mental illness or how it differed from cognitive dysfunction or how either of them differed from bad morals. It didn't matter because there wasn't really any treatment anyways.

There were attempts to separate out those who couldn't care for themselves from those who wouldn't. Bethlehem Hospital is an example of this and that did not work out particularly well. It gave us the word bedlam in english which means loud confusion. It was a popular tourist attraction as well with the well-to-do paying fees to watch the capers of the mentally ill while they suffered. So prison or a sideshow.

Against this backdrop the asylum model was pretty humane. By the early 20th century medicine was getting a hand in mental illness, and there was general agreement that we shouldn't make their lives miserable for our own amusement. At its best, an asylum would be in a rural location with an associated farm. Residents would work if they were able tending animals or gardens, or maintaining the buildings or working in the kitchen. The produce would provide some income and partially supply the kitchens. What developed then was a self contained community with some residential staff.

One of the best documents for this model is Erving Goffman's Asylums published in 1961. It examines the asylum model in great detail. It is worth mentioning that there was anti-psychiatry movement at that time that continued build steam through the 1970s. Goffman writes with an eye towards that movement that often portrays the staff as being the beneficiaries of the institution. One Flew Over the Cuckoo's Nest shows this in a setting reminiscent of bedlam like torture. Inherent Vice portrays it in a humorous fashion with psychiatrists dining on linen table cloths and eating gourmet meals prepared by patients. Both are fictionalized exaggerations, but it's true of any institution that lacks strong oversight that they will be highly variable depending on the specific adminstration and culture at a locale. This is true of prisons as well.

So that was kind of the situation in 1980 when Reagan came into office closed them all down. The mentally ill now live on the streets. I worked in this area for many years. It's funny to me how a modern best practice would have a stable community setting with residential staff and meaningful work for people according to their capacity. Sound familiar?

I used to do care for developmentally disabled people, and one of the clients my agency worked with was in a surviving mental institute in the late 90s. In some aspects, it was better than some of the stories might suggest. They got her on the right meds at the right dose, which let her regain independence with minimal support.

However, they did pull all her teeth upon admission because it was cheaper than fixing them. They issued her one pair of dentures, and failed to replace them when another patient broke them. One of the first things she did after getting out was to get new dentures, and she cried when she finally had teeth again and didn't need to be on a blended food diet any more.

As much as I hate to say it, this wasn’t all on Reagan.

Up to and around that time there was already a big push away from institutionalization in general which led to the neglected conditions Geraldo made a name for himself reporting over.

Prior to there were lots of overlapping programs that allowed social workers and mental health workers to utilize that helped maintain a relationship between the patient and the system. Community outreach, in home programs… way more funded.

Over time that stuff was neglected and shuttered forcing folks into facilities which were then villainized and shuttered themselves. The face of mental healthcare changes a lot before that bow broke.

Check out Geraldo Rivera's break out

They were legitimately that bad for the most part. Some were better than others of course, but the best of them were closer to a bad nursing home. The worst were legitimate atrocities. You didn't put someone there to get better. Those who did were the rarest of exceptions, and were people whose problems had more to do with unhealthy environments. You put people in an asylum to keep them contained.

It's important to remember, psychology is a relatively young discipline. Historically the best mental counseling was folk wisdom and religion. People had all kinds of ideas, often grounded more in superstition than any kind of demonstrable, repeatable evidence (a problem which unfortunately persists in the field, though it's getting better). Asylums were more like dubious research labs than medical facilities and the mentally ill were closer to lab rats. Caged lab rats.

The field still has a long way to go, there's still a lot we don't know that's out there to learn, but the methods and techniques are a lot better than they used to be. A lot better.

There's a lot of reasons not to like Regan, but he did get some things right. That was one of them.

It was bad