The National Library of Medicine (NLM) has created a new traveling and digital exhibit, Care and Custody: Past Responses to Mental Health, which explores how society has responded to people with psychiatric disabilities in the United States throughout history.
For contemporary health care providers and learners, understanding this important, and under-examined, history can inform clinical practice with essential context.
Did you know that state institutions, which many associate with films like One Flew Over the Cuckoo’s Nest, started because of reform campaigns? Advocates like Dorothea Dix agitated for the creation of asylums to keep people with mental illness out of poor farms, prisons and jails. In her 1843 address, “Memorial to the Legislature of Massachusetts,” Dix plead for funding “an Asylum for this class, the incurable, where conflicting duties shall not admit of such examples of privation and misery.”1
In Oregon, Dr. James C. Hawthorne founded the state’s first inpatient psychiatric facility, the Oregon Hospital for the Insane, which operated on Southeast 12th Avenue and Southeast Salmon Street from 1862 to 1883. His practice followed the recommendations of reformers like Dix, and emphasized balanced diets, fresh air, and minimal restraints for patients.2
In OHSU’s digital collections, we have a small series of reports from the Oregon State Insane Asylum, the state-run facility that took over care of patients after Hawthorne’s asylum closed following his death. The biennial reports detail the patient population, expenses and improvements over the course of each year. For example, the 1889 report notes the addition of a billiards table and three hundred additional volumes to the library.3 The reports also offer a window into the social construction of mental illness as it has changed over time; the “forms of disease” identified for the 384 patients admitted during a two-year period included “idiocy,” “imbecility,” “acute/general melancholia,” and “epileptic insanity” (epilepsy was considered a “neurotic” disorder related to insanity in this era).4
Some campaigned against involuntary confinement in the nineteenth century, pointing out how unequally such laws could be applied. Care and Custody highlights women’s rights and psychiatric patient’s rights advocate, Elizabeth Packard. Packard’s experience exemplifies the issues facing nineteenth century women entangled in laws around property, marriage and involuntary institutionalization. Packard’s husband, Theophilus Packard, had Elizabeth committed after she questioned some of his religious views and objected to the sale of a property that she brought to the marriage.5 She spent 3 years in the Jacksonville Insane Asylum in Jacksonville, IL before being released (to her husband’s custody!). Packard’s subsequent battle to regain her independence, her property, and her children lasted another 6 years. She later founded the Anti-Insane Asylum Society and wrote extensively about her experiences, including in the 1873 volumes, Modern Persecution: Insane Asylums Unveiled and Married Woman’s Liabilities. (We’ve posted about our copy of the set on Instagram, and you can access a full digital version of Volumes I and II via Internet Archive courtesy of the Cushing-Whitney Medical Library.)
By the mid-twentieth century, it became clear to many that state asylums, which originated with the work of impassioned reformers like Dix, led to institutions that kept people in inhumane conditions against their will. This led to a movement toward deinstitutionalization: In addition to closing inpatient institutions, advocates and policymakers in the 1950s–1970s proposed robust networks of community behavioral health centers and resources, so that people could access necessary services while remaining in the community.6
Even before the deinstitutionalization movement of the 1950s-1970s, some mental health professionals attempted to advocate for community-based models of care for some populations, such as minors involved in the court system. In the 1941 document, State Psychiatric Service for Rural Courts (available via OHSU’s Digital Collections), a University of Oregon Medical School professor addresses judges with an aim of explaining the benefits of clinical treatment, rather than confinement, for “juvenile offenders.”7
As explored in Mental Health and Incarceration, the educational module associated with Care and Custody, the history of mental health care and confinement is closely connected to the history of mass incarceration in the United States. While psychiatric inpatient facilities continued to close in the 1970s and 1980s, the promise of funding for community-based services did not materialize, and additional social safety net programs faced dramatic cuts. Without robust community care networks, prisons and jails increasingly took the place of asylums as custodial institutions for people with psychiatric disabilities.8 This led to a disproportionate number of underserved people, particularly from communities of color, unhoused and caught up in the carceral system.9
Today, incarcerated people are five times more likely than the general population to have a serious mental illness.10 In fact, the largest mental health facility in the United States is currently Cook County Jail in Illinois.11 People with psychiatric disabilities who have been incarcerated face barriers to accessing housing, care and services. This dynamic is described in greater detail in the 2016 OHSU School of Nursing publication, “Release date: A Relational Perspective on Transition from Prison,” by Ariana Cooley and Samantha Ross (available via OHSU’s Digital Collections).12
Besides the accounts of well-known historical activists like Elizabeth Packard, what’s frequently missing from discussions of treatment for people with psychiatric disabilities are the voices of those most affected: the patients. Here at OHSU, we are the stewards of the records of MindFreedom International, a patient-driven advocacy group started in the 1970s. The organization grew out of a collaboration between grass-roots organizations including the Mental Health Patients Liberation Front (MPLF), of Boston, the Network Against Psychiatric Abuse (NAPA), of San Francisco, and the National Association for Rights Protection & Advocacy (NARPA).13 While this collection is not currently digitized, the finding aid (collection guide) is available online for review. Contact us if you are interested in accessing this collection.
Resources for further study
Ben-Moshe L, Carey, Allison C. Disability Incarcerated: Imprisonment and Disability in the United States and Canada. Palgrave Macmillan; 2014.
Goeres-Gardner, Diane L. Inside Oregon State Hospital: a History of Tragedy and Triumph. The History Press; 2013.
Parsons, Anne E. 2018. From Asylum to Prison: Deinstitutionalization and the Rise of Mass Incarceration after 1945. Chapel Hill: The University of North Carolina Press.
Prison Policy Initiative, Mental health data visualizations.
2 Mike Mata, “James C. Hawthorne: An Asylum and a Boulevard,” Public Health PDX, February 7, 2017, Portland State University History Department. http://publichistorypdx.org/2017/02/12/james-c-hawthorne-asylum-boulevard/
3 “Third Biennial Report of The Board of Trustees and of The Superintendent of the Oregon State Insane Asylum for the Two Years Ending November 30, 1888.” Public Health in Oregon digital collection, OHSU Digital Collections. https://doi.org/10.6083/M4GF0T0K
5 “Elizabeth Packard – Legal and Mental Health Reformer,” Illinois History and Lincoln Collections blog, March 28, 2019. https://publish.illinois.edu/ihlc-blog/2019/03/28/elizabeth-packard-legal-and-mental-health-reformer/
6 “Deinstitutionalization and Community Support: A Report,” July 28, 1975. [MS C 493, Bertram Brown Papers 1884-1988, Series 5] Modern Manuscripts Collection, History of Medicine Division, U.S. National Library of Medicine. https://collections.nlm.nih.gov/bookviewer?PID=nlm:nlmuid-100961975X1680-leaf#page/5/mode/1up/search/july+28
8 Ann Parsons, From Asylum to Prison: Deinstitutionalization and the Rise of Mass Incarceration after 1945 (Chapel Hill: The University of North Carolina Press, 2018), 69-122.
9 Vera Institute of Justice, The Burden of Mental Illness Behind Bars. June 21, 2016. https://www.vera.org/the-human-toll-of-jail/inside-the-massive-jail-that-doubles-as-chicagos-largest-mental-health-facility/the-burden-of-mental-illness-behind-bars
10 Prison Policy Initiative, “Prevalence of serious mental illness among jail inmates.” 2019. https://www.prisonpolicy.org/graphs/jails_mental_illness.html
11 Matt Ford, “America’s Largest Mental Hospital Is a Jail,” The Atlantic, June 8, 2015. https://www.theatlantic.com/politics/archive/2015/06/americas-largest-mental-hospital-is-a-jail/395012/
13 Historical note, MindFreedom International records, collection 2013-026. Historical Collections & Archives, OHSU Library. http://archiveswest.orbiscascade.org/ark:/80444/xv71517