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Poverty, Taxes and Insanity: Early American and Australian Schemes for Funding the Care of the Mentally Ill

Federal mental health services, History of dumping mentally ill patients, Mental health funding, Mental illness funding, mentally ill homeless, mentally ill in prison, Poverty, , ,

By Stephanie Ramage

Presented to the American Political Science Association Conference in Savannah, Ga. in November 2014

How to provide food, shelter and care for the mentally ill is not a new issue. It is likely as old as humankind. But today caring for the mentally ill is a problem that has enormous impact on virtually every facet of public life in America: From the burden placed on medical facilities, to the increased need for prescription medication among a mobile and low-income population, to chronic homelessness caused by an inability to manage self-care, to the cost of public safety resources involved in addressing the incidents that result, to the cost of court proceedings to adjudicate such cases, to the budgets of prisons which now, in Georgia, house more diagnosed mentally ill than do all existing mental health care facilities, both public and private, combined.

Gerald Grob began his landmark study “Mental Institutions in America” (1973) with a quote from neurologist E.C. Seguin at the proceedings of the Conference of Charities and Corrections in 1880: “It is fair to say that in the present state of psychiatry in America, to be pronounced insane by physicians, by a judge, or by a jury, means imprisonment for months, for years, or for life. To put it another way, there is a disease which reduces its victim to a level with persons accused of crime, and exposes them to loss of liberty, property and [to] unhappiness.”
Seguin was making the point that asylums were nothing more than prisons. Today, we have dispensed with the sham—a jail pretending to be a hospital—and we openly admit that the mentally ill are jailed. They usually become a part of our penal system through the commission of a minor crime or behavior deemed threatening to themselves or others, a process that I have seen in my former career as an investigative reporter and more recently in my present official capacity, over and over again.

Because of the nature of their crimes, they are rarely jailed for long and often are released back onto the street, where many live as part of the homeless population, until they are incarcerated again, for a few days, for a minor infraction, and, once more released.
In terms of effective treatment, imprisoning the mentally ill is not an excellent policy, but it is a very old one, one that even the English Poor Law of 1601 aspired to ameliorate. It is that law which set the tone for similar laws in America and Australia, so that is where we begin in trying to figure out how it is possible that civilized societies have made so little progress over so many centuries in the funding of the care of the mentally ill.

This paper attempts to retrace the early steps toward public mental health care systems in America and Australia. Both systems grew out of England’s Poor Laws, but both systems have also been shaped in part by their place in time. A look at both helps provide more insight into how the political climate at the time of their settlement deeply influenced the mental health care mission—with America embracing the Poor Law of its mother country, and Australia eschewing it, either because Australia’s early settlers were already wards of the state and there was little opportunity for taxation or because the convict settlers feared the resentment that they believed the Poor Laws had stirred up against the poor back home. Timing for each government had immense impact on the mentally ill populations they were supposed to help, particularly in how they chose to fund their patient care.

Most significantly, this paper will address the roots of the very limited public funding options for mental health services these modern Anglo societies explored over a span of nearly 600 years, options that today’s readers might find chillingly familiar. The old adage that you if do not know your history, you are bound to repeat it was the guiding light of this paper. There must be great ignorance regarding the history of public funding mechanisms for the care of the mentally ill, because the process of taxation and inadequate public expenditure on either at-home care by relatives or incarceration in the penal system with a small slice for institutional mental health care, would be familiar to parish officials in the 16th century. The pleadings and petitions for financial assistance by families caring for autistic children and adults or deranged relatives in the late 1600s would appear to be echoing today in the halls of our current legislatures.
When a friend asked me to sum up what I’ve learned so far from my research, I responded that we humans have overestimated the prevalence of sanity for many centuries. I hope this paper might contribute a tiny bit toward illuminating the ubiquitous nature of mental illness throughout our history and the equally common inadequate response of government.

Literature Review

Fully understanding the concepts discussed in this paper requires an understanding of a few terms common in the study of the English Poor Law but rare in other disciplines. The first is the term “the impotent.” Because the first iterations of the Poor Law don’t specifically refer to the insane, but instead to “the impotent”—those who were unable to work—I found it necessary to contact Paul Slack, pro-vice-chancellor of Oxford University and probably the world’s leading expert on the history of the Poor Law, to request some clarification. I needed to know, before advancing my research, whether “the impotent” would have included the mentally ill. Slack, the author of “The English Poor Law, 1531-1782,” responded in the affirmative. Indeed, he emailed me, the mentally ill who were unable to support themselves would be included in the Poor Law’s overarching classification of “the impotent.”

Other important terms are “indoor relief,” which means putting the poor to work in an almshouse or workhouse, and “outdoor relief” which means cash payment that allowed the poor to remain at home with their families. Additonally, “Quarter Session,” refers to the four-times-a-year municipal court sessions that, thanks to the remarkable research of Peter Rushton into Quarter Session records used in his journal article, “Lunatics and Idiots: Mental Disability, the Community and the Poor Law in Northeast England, 1600-1800,” have yielded a trove of court records related to the funding of mental health services in the early modern period.

The mentally ill themselves are referred to variously in these historic records as “distracted,” “lunatic,” “insane,’ “ideot” or “idiot.” Having been grouped with all other impotent individuals in need of support in the Poor Laws of the late sixteenth century, as the law was refined they were divided into two distinct groups for the purposes of public benefit distribution: idiots—those with an untreatable mental disorder which manifested as a constant inability to carry out simple functions such as counting to 20 or recognizing the faces of close family members—and lunatics, those who had been fully functioning at one time or were still occasionally fully functioning but were known to have suddenly become incompetent or irrational or were given to fits of insanity. This is according to Rushton and to William Parry-Jones, author of the iconic “The ‘Trade in Lunacy’: A Study of Private Madhouses in England in the Eighteenth and Nineteenth Centuries.”

The English Background

The earliest mention of the mentally ill in English legal documents was in the 13th century in a set of inheritance laws that were concerned with making sure “idiots” could not inherit an estate and that “lunatics” could at least be temporarily deprived of their estate. (B. Clarke, 1975, p. 58)

The distinction was important, as mentioned in the previous section, in terms of whether the mentally ill were believed to be incurable and unable to look after themselves, as with “idiots,” or were only temporarily incapacitated by a fever or a fit or a spell of melancholia, as was the case with “lunatics.” But the reference is to what families could do about inheritances. The implication is that families were in charge of the mentally ill. The government made no mention of getting involved with their care.

One of the earliest English records referring to the intersection of government and the care of the mentally ill was also one of the first recorded instances of NIMBY (“not in my backyard”). It was Richard II’s order that four insane men living with priests at what was called the Stone House at Charing Cross be moved to St. Mary of Bethlehem Hospital so they wouldn’t be so close to his palace. This was in 1377. (Clarke, 1975, p. 79) But it tells us more than merely the incidental fact that they were moved. It also tells us that there were mentally ill citizens who were not cared for by their families. Not only were they mentioned but, significantly, there was no mention of demonic possession, being under a witch’s spell or similar paranormal things that people today tend to think of when (and if) they think of the treatment of the mentally ill in the fourteenth century. “Mental Disorder in Earlier Britain” refers to Chaucer’s list of eminent “mad doctors” in illustrating “one general point about them which can be emphasized is the firmness with which mental disorder—or what we should consider mental disorder from the descriptions—was kept within the framework of a rational pathology.” (Clark, 1975, p. 85)

So, we know that there were mentally ill who were not cared for by their families and that their mental condition was seen as an illness. That being the case, it would stand to reason that they would be cared for by someone other than family and they would be cared for by rational, rather than supernatural, means.

In medieval times, they were often cared for alongside the physically sick, the homeless and vagabonds at monasteries that included at least a hospital wing. By the time Richard II was having his mentally ill neighbors removed to a hospital run by a religious order, there were 1,100 such hospitals in England alone. They provided care for the needy through poor relief collected as a tithe by the church. Up to a fourth of the tithe was distributed across the diocese to care for the impotent. (Trattner, 1974, p. 48)

When Henry VIII seized the monasteries and hospitals from the Catholic Church, he gave St. Mary of Bethlehem to the City of London, in 1547, as a hospital for the insane, and it remained the only public hospital for the mentally ill until the early 1700s. (Parry-Jones, 1972, p. 6) But the destruction of the hospitals set something else in motion—greater reliance on public, rather than private, resources to help the poor and impotent.
“The dissolution of the monasteries, chantries, religious guilds and fraternities in the 1530s and 1540s radically reduced existing sources of charity,” Slack writes. (Slack, 1995, p.14)

He goes on to explain that the successive laws that would eventually evolve into the great Poor Law of 1601 contained three principle features: “The first, and ultimately the most important, was the poor-rate, the compulsory assessment in each parish which financed outdoor relief to deserving indigent households. In 1563 secular sanctions were threatened against those who refused to contribute to collections for the poor. In 1572 justices of the peace were empowered to determine the size of contributions, thus turning them into an imposed tax: they were to assess richer parishioners after surveys of the poor had been made to see what money was needed. Finally, in 1598, the ground was prepared for the widespread adoption of rates, when the main responsibility for levying them was transferred from overworked justices to the churchwardens and overseers of every parish.” (Slack, 1984)

The Poor Law of 1601 codified the government’s responsibility to the poor by combining and expanding its earlier versions. It didn’t specifically mention the mentally ill, but it was designed to ensure the care of those who could not care for themselves. (Parry-Jones, 1972. p. 6) The law made families legally responsible for their kin up to three generations, so that grandparents were responsible for their children and grandchildren who could not work and, similarly, grandchildren were responsible for the care of their parents and grandparents. The law divided the needy poor into three categories and prescribed a particular remedy to each: for children, apprenticeship to a trade, for the able-bodied poor, work on public projects, for the “impotent”—those who had some physical or mental infirmity making them unemployable—cash assistance (William I. Trattner, “From Poor Law to Welfare State: A Social History of Welfare in America,” Sixth Edition, 1974). All of these remedies were funded with a tax assessed against every landowner in a parish, with the active support of the church in collecting the tax and distributing the revenue. It was the local priest who served as administrator of aid to the poor, but it was the justice of the peace who could bring charges against those who did not pay the tax. (Trattner, 1974, p. 54)

Rushton’s examination of court records in North-East England, the Quarter Session records, left him with the “firm impression that they [local governments] reacted to the problems in a coherent and consistent manner within the structure of limited resources, a concern for public order, and a division of welfare responsibilities between the family and the community.” (Rushton, 1988, p. 34)

A sample of the Quarter Sessions records has haunting resonance today. They tell a story of poverty either initiated or exacerbated by mental illness, families struggling to care for their ill kin, which the law required them to do and, in any case, they did because there were no humane options: “With regard to idiots, the cases were nearly always brought by relatives faced by financial difficulties. Families were in desperate poverty, especially if they had had to care for someone for many years. James Twizell was looked after for forty years by his sister and brother-in-law, his only relatives who, in theory, had no legal obligation to care for him. He was “born a fool which is the cause of his poverty.” (Ibid, p. 39)

A Northumberland widow took care of her two granddaughters, telling the court “youngest is about thirty years of age and neither of them can [count] to twenty …. I am burthened something with them because they are not capable of service.” she said. (Ibid.)

The only instance of idiocy causing anxieties about public order occurred in Northumberland in 1702, when Margaret Williamson of Allendale petitioned concerning her “innocent” son, a twelve-year-old “incapable of knowing any by name or face yea his own mother”. He was described as “unruly”, and so “past Government that without a continual eye had unto him she is in daily fear of some ill to be done by him either to her, himself or to some others”. The neighbours were endeavouring to compel her to “attend him with watchful eye in the house”. She had a second child by a second (disabled) husband, and requested financial aid to “keep her in the house with him which will be the safety of the neighbourhood.” (Ibid.)

It wasn’t until the Act of 1714 that a distinction, as related to alms or poor relief, was made between “impoverished lunatics and ‘rogues, vagabonds, sturdy beggars and vagrants.” The Act allowed two or more justices of the peace to authorize the arrest of lunatics who were “furiously mad or dangerous.” The introduction of the “dangerous lunatic” who needed incarceration had been made. The cost of keeping a pauper lunatic incarcerated was borne by the lunatic’s parish. Some parishes handled this by “boarding out”—paying a family to look after them in a private home. These homes would become known as “madhouses.” (Parry-Jones, 1972, p. 6-14)

The Mad in America

The American colonies were settled by England between the passage of the Poor Law of 1601 which codified responsibilities to the poor and the Act of 1714 which allowed the confinement of the mentally ill.

Thus, the colonists brought with them the idea of three generations of family being responsible for their own, with government relief acting as a failsafe to be used by those who did not have family able to assist them. “Government” meant the local selectmen, the town council, and parish leaders. As was the case in England, supporting the indigent required a collection of taxes from the local residents.
The colonists took Poor Laws, laws that assigned public funding to relief for the old, invalid or orphaned, in stride. The governing thought, according to William P. Quigley in “Work or Starve: Regulation of the Poor in Colonial America” (1996), was that poor relief should be given only to those who were unable to work.

Although the family was primarily responsible for its members who became insane, the community could never remain “completely aloof from the problems of mental disease.” This was either because the ill person was a threat to himself and others, therefore a public safety hazard, or because he or she was unable to work, meaning support for the individual either impoverished the family or fell to the community. (Grob, 1973, p. 4)
In 1641, Massachusetts Bay colony passed a relief law referring to “distracted persons,” which was followed up with a measure codifying the seizure of the distracted person’s property by the government and, finally, in 1694, “An Act for the Relief of Ideots and Distracted Persons” that laid out how taxation for, and expenditure on, the mentally ill was to be carried out. Other colonies followed suit. (Ibid, p. 8)
The actual funding of such relief was the real challenge. Resources were scarce in the colonies and so were the people who were expected to work for them. Because the local community was responsible for paying for the care of its own sick and mentally ill, proof of residency was a requirement in most settlements.

“Virtually every colony passed settlement laws, which stipulated that all individuals eligible for relief had to prove that they were legal residents in the community in which they lived. The minimum period necessary to gain legal residence tended to vary from colony to colony; in most it ranged from three months to one year. Those persons unable to establish legal residence could, under certain conditions, be compelled to leave…The reason for this procedure was to absolve the town from all obligation to aid individuals who required help and assistance but did not meet residency requirements.” (Ibid, p. 7) Therefore the colony, rather than the local township, would theoretically be responsible for the needy individual, although the colony might decline to care for them as well.

There is no way of knowing “how many so-called lunatics were treated at home or in the homes of families subsidized by the community to care for them, but it was probably the majority. Nor do we know how many were in jails or almshouses or simply wandered about in various stages of neglect,” Dr. Norman Dain wrote in the December 1976 edition of the Bulletin of the New York Academy of Medicine. “But we do know that sometimes communities tried to free themselves of the cost of caring for their insane by depositing them surreptitiously in alien townships. In all likelihood domestic care was, from the community’s point of view, the cheapest and safest kind of care-and apparently some persons preferred it even after more mental hospitals opened.” (Dain, 1976, p. 1182)

Boarding out was one way that colonial townships handled the burden of care for the sick and needy. Often, a township would hold an auction of sorts at the pub following a meeting of the town council and citizens would bid on the care of a sick person who had no family to care for them. Because it was the township’s residents who would pay for the care through the poor tax, the lowest bidder won, so the household that could care for the sick individual with the least expense to the town would be awarded the care of the person. Some towns required visitors to put up collateral against sickness. (Trattner, 1974, p. 68)

The towns that bore the greatest burden in terms of providing for the mentally ill poor tended to be large port cities. Not only did they become home to immigrants, but they also, even before American independence, were places for refugees from war, like King Phillip’s War, for example, in 1675, when English settlers took refuge in Rhode Island from the hostilities on the French Canadian border. The port cities, Newport, New York, Boston, Philadelphia, and Charleston had difficulty allocating the local poor tax because it was levied against a smaller group than the ever-burgeoning newcomers. The result was that the colonial assemblies, the local legislatures, were petitioned to allocate taxes from the entire colony, not just the local township, to build facilities for the insane.

That is how the Pennsylvania Hospital, the very first institution for the sick and mentally ill in the colonies, came to be built. Dr. Thomas Bond enlisted the help of Benjamin Franklin in persuading the colonial government. The petition opened with:
“That with the numbers of people, the numbers of lunaticks, or Persons distempered in mind, and deprived of their rational faculties, hath greatly increased in this province. That some of them going at large are a Terror to their Neighbours, who are daily apprehensive of the Violences they may commit; and others are continually wasting their substance, to the great injury of themselves and families, ill-disposed persons wickedly taking advantage of their unhappy condition, and drawing them into unreasonable bargains…” (Grob, 1973, p. 18)

But the first hospital devoted exclusively to the care and treatment of the mentally ill was in Virginia. It was funded out of receipts from the colony’s Poor Law tax. It was completed in 1773 and its operations were shortly thereafter interrupted by the Revolutionary War.
Only one other colony succeeded in establishing a public hospital especially for the mentally ill, New York. The royal governor supported its establishment, so that the colonies would have hospitals funded by the poor tax just as the mother country did. But it was never to be. A fire and then occupation by British troops during the Revolutionary War delayed its opening until 1791, when it was used for both the mentally ill and those with other sickness.

Meanwhile, Australia was founded as a penal colony.

Convict Australia

Even as the First Fleet prepared to sail for Australia with its cargo of an incarcerated workforce in May 1787, the colony’s first governor, Arthur Phillip was already charged with the responsibility, on behalf of the Crown, of the welfare of “ideots” and “lunaticks.” His commission granted him authority over them with these words: “And whereas while such ideots and lunaticks and their estates remain under our immediate care, great trouble and charges may arise to such as shall have occasion to resort unto us for directions respecting such ideots and lunaticks and their estates, We have thought fit to entrust you with the care and commitment of the custody of the said ideots and lunaticks and their estates…we do by these presents give and grant unto you full power and authority…” (Bostock, 1968, p. 15)

In England, the poor law was expanded over time to include assistance to the working poor, but it was also abused by both its administrators and its beneficiaries. A subsidy to farm laborers’ wages enabled farmers to pay workers inadequate wages, safe in the knowledge that the taxpayers would make up the difference. Additionally, “outdoor” assistance, public assistance that was paid in cash to the unemployed or through jobs on works projects, was increasingly phased out in favor of “indoor” assistance, workhouses where arduous labor was paid in provisions so meager that they were far less than what one could get on one’s own by finding work. (Hirst, 2009, p. 127).
By the time the first shipment of convicts were sent by the Crown to settle Australia in January 1788, the English Poor Law was on its way out of favor. With a labor shortage in Australia and with land available in exchange for work, no one, convict nor free landowner, wanted a Poor Law. They didn’t want the tax and they didn’t want the workhouses. So, the tax to support the law was not assessed against Australian property. Without such a source of revenue, the Australian colonies relied on private charities to care for the poor. However, the demand soon outstripped the supply as the continent filled up with more people. To fill the gap, the Australian states subsidized the private charities, selling off land to raise revenue to do so (Ibid, p. 127).

“The time at which the Australian colonies were founded was certainly crucial to their determination not to reproduce the English poor law,” writes Hirst. “American colonies, some of them critical of much in England, adopted poor laws as a matter of course. However, during the period of the founding of the Australian colonies — from the late eighteenth century to the 1830s — the poor law ceased to be an accepted part of English life.” (Ibid, p. 125)

England may not have needed the Poor Laws as much once the Australian penal colony began acting as a safety valve for English prisons, but there were still mentally ill English citizens who were unable to work and did not have family to care for them. As the English middle class grew, the Poor Laws were resented and assistance to the poor and the sick waned.

In 1800, James Hadfield’s attempted assassination of King George III and the court’s subsequent finding of “not guilty by reason of insanity,” paved the way for the “Criminal Lunatics Act.” The act required that a person who committed a felony by reason of insanity be incarcerated whereas, previously, those found guilty by reason of insanity were usually sent home to the care of their families. The Criminal Lunatics Act recognized the criminally insane as a group distinct and separate from either the criminal population or the strictly mentally ill. The criminally insane could be locked up preventively because of the harm they might do someone in the future.

The Act was used more frequently in Australia.

“The precise reasons for the widespread use of [the Criminal Lunatics Act in Australia] as the means of committing people to the asylums are complex—they have to do with the absence of the poor law in the colonies, just as in Ireland, where the absence of an effective poor law seems to have encouraged an overuse of the ‘dangerous lunatics’ provision.” In 1838, the law would be updated to require the criminally insane to be sent to an asylum rather than jail. (Mark Finnane, “Madness in Australia: Histories, Heritage and the Asylum,” edited by Catharine Coleborne and Dolly MacKinnon, p. 27)

It’s no mere coincidence that England’s Poor Laws were struck down in 1834. With the fulfillment of its “transportation” policy, England was getting rid of its poor. It was exporting them through criminal laws, the courts and the penal colonies of Australia. With an alternative available, there was less need for the hated poor tax, the workhouses, or the prison hulks. In Australia, the convicts—mostly poor repeat offenders, with some political protestors among them—were out of sight and out of the minds of members of Parliament who were vexed by a growing population of young people and a shrinking number of manual labor jobs brought on by enclosure and industrialization. The result of these two factors was a completely overwhelmed prison system.

As explained by Robert Hughes in his history of Australia’s convict founders, “Fatal Shore,” (1986) the “System” as England’s deportation program was known, reached its pinnacle in terms of efficiency and breadth of application in the period between 1831 and 1840.

“In those years, 43,500 male and 7,700 female convicts sailed for Australia—a total of 51,200 people, more than the previous two decades decantation on the fatal shore. The most active year was 1833, when 6,779 prisoners of both sexes were shipped to Sydney and Van Diemen’s Land. By then, transportation had been accepted by most respectable Englishmen as the best of all answers to crime…” (Hughes, 1986, p. 303)
Transportation was not only seen as the best answer to crime, but to the “criminal class”—a near mythical segment of English society who made their living through crime and had no respect for authority or the law. Hughes wrote that Australia was expected to “swallow an entire class—the criminal class.” (Ibid)

Without a Poor Law to assess and distribute tax money, Australia’s early settlers, 160,000 convicts, relied instead on charity. “Since charity was a vital institution, its own inadequate funds had to be supported by government money. It might look as if Australia by this arrangement had acquired a poor law. The charitable bodies maintained institutions for the aged poor, orphans and ‘fallen’ women; they distributed outdoor relief to people whose distress arose from a variety of causes; and the taxpayer met a large part of the bill… The arrangements were indirect in more ways than one. Until the late nineteenth century no colonial government imposed a direct tax on land, income or wealth. The governments survived by selling off their capital assets — land — and by regressive taxes on imports. The government-supported charities did not involve a tax on land; it was that which was the distinguishing mark of the poor law.” (Hirst, 2009, p. 127)

It was, to echo Hirst, the manner of funding public assistance that was of key importance to Australian colonists. They did not want to pay a tax to support the poor.

A century later, Australian colonists had a new problem: More Australians living into old age. Because colonial Australia’s public safety net was a patchwork of private charities whose presence varied from state to state (depending on the subsidies they received from government) certain classes of poor could fall through the cracks altogether because of where they happened to be. For example, in New South Wales, hospitals did not want to accept the elderly who were sick, while in Victoria, charitable asylums did not have enough room for the elderly who were poor. Left without another option, the police, as an act of mercy, were prone to imprison the elderly (Hirst, 1975).

Bibliography
Bostock, John. 1968. The Dawn of Australian Psychiatry. Glebe, New South Wales. Australian Medical Publishing Company.
Clarke, Basil. 1975. Mental Disorder in Earlier Britain. Cardiff, Wales. University of Wales Press.
Dain, Norman. 1976. From Colonial America to Bicentennial America: Two Centuries of Vicissitudes in the Institutional Care of Mental Patients. New York. Bulletin of the New York Academy of Medicine, Vol. 52, Issue 10.
Finanne, Mark. 2003. Madness in Australia: History, heritage and the asylum. Edited by Catharine Coleborne and Dolly MacKinnon. St. Lucia. Queensland University Press.
Grob, Gerald N. 1973. Mental Institutions in America, Social Policy to 1875. New York. The Free Press.
Hirst, J.B. 1975. Keeping Colonial History Colonial: The Hartz Theory Revisited. Australian Historical Studies Journal. Melbourne. Vol. 16 Issue 64
Hirst, John. 2009. Sense and Nonsense in Australian History. Melbourne. Black, Inc./Shwartz
Hughes, Robert. 1986. The Fatal Shore. New York. Random House.
Parry-Jones, William L. 1972. The ‘Trade in Lunacy’: A Study of Private Madhouses in England in the Eighteenth and Nineteenth Century. London. Routledge and Kegan Paul.
Rushton, Peter. 1988. Lunatics and Idiots: Mental Disability, the Community and the Poor Law in North-East England, 1600-1800. London. Medical History Journal.
Slack, Paul. 1995. The English Poor Law, 1531-1782. Cambridge University Press.
Slack, Paul. 1984. Poverty in Elizabethan England. History Today. Volume 34. Issue 10
Trattner, Walter. 1974. From Poor Law to Welfare State: A History of Social Welfare in America. New York. The Free Press.

Explanation of How America’s Mental Hospitals Were Gutted and How to Fix the Problem

Poverty, Taxes and Insanity: Early American and Australian Schemes for Funding the Care of the Mentally Ill

President Kennedy’s Community Mental Health Centers plan failed due to racial and labor tensions, a failure which has left this country with a legacy of heartbreak and shame.

The bill was the work of an Alabama Senator whose daughter suffered from mental illness. Sen. Hill crossed political lines to craft and champion Kennedy’s CMHC bill of 1963. But Northern senators upended the bill, claiming that funding for staff should be withheld until desegregation of mental hospitals in the South could be verified. This stance ignored many cultural nuances, among them that black families often did not want their loved ones in the care of white-majority hospitals for fear of neglect and abuse. This was not a sentiment that blacks at the time felt safe in voicing, so a crucial component of public discourse on the matter was missed.

To complicate matters, Northern lawmakers who were heavily supported by organized labor demanded that all personnel funding for the centers be withheld unless their Southern counterparts agreed to hire only union labor. Given the climate of the time, one can’t help but think that they had to know this would be the death knell of the bill. And it was.

While construction of the first 400 Community Mental Health Centers was funded, the staffing part of the legislation failed, so no payroll was provided.

The States, which were the primary source of care for the mentally ill—the vast majority of mental hospitals were state-owned, funded and run—took passage of the construction bill as an opportunity to evict thousands of patients and to begin phasing out their hospitals. This act on the part of the States had enormous consequences.

With no Congressional approval for paying staffers, the Federal government scrambled to find some way to take care of the hordes of sick people the States were dumping. What they came up with was a mish-mash of Medicaid, Medicare, and SSDI funding passed as part of the DHHS budget in 1965.

The States then transferred their patients to nursing homes where the Federal Medicaid, Medicare and SSDI checks were sent to the patients individually, but in many cases, the patients never got them. Many mentally ill people, some of them young, died in nursing homes of neglect and abuse over the next several decades as the nursing home operators took their federal checks.

Others–an exact number is hard to come by as records were thrown into chaos–went home to their families who were in some instances ill-equipped to care for them despite the desire to do so or, sadly, didn’t want them, ultimately ending up out on the street or in jail due to minor offenses or “compassionate arrests,” which means that law enforcement locked them up to give them shelter.

This sorry state of affairs didn’t happen over night. As legislators and administrators across the nation fought State budget cuts to hospitals and programs, it took decades to reduce our mental hospital system to the inadequate thing it is today.

Click on the following link to view the slideshow I prepared for my Public Policy masters program at Georgia Tech.

Ramage Slideshow Mental Health legislation proposal

“The most significant effort the Congress of the United States…has ever undertaken”

Federal mental health services, Mental health and public policy, Mental health funding, mental illness and public policy, Mental illness funding, Public Policy

This folder contains a press copy of President John F. Kennedy’s statement in the White House Cabinet Room upon signing S. 1576, the Community Mental Health Act of 1963 (also known as the Mental Retardation and Community Mental Health Centers Construction Act of 1963), an act to provide federal funding for community mental health centers and research facilities devoted to research in and treatment of mental retardation. He also announces the creation of the Department of Education Division of Handicapped Children and Youth.

http://www.jfklibrary.org/Asset-Viewer/Archives/JFKPOF-047-045.aspx

Letters to a Future President: Early Warnings of the Failures of Deinstitutionalization

Mental health funding, mental illness and public policy

By Stephanie Ramage

The deinstitutionalization movement, which aspired to make mental institutions largely obsolete by releasing mentally ill patients into planned “community care” programs, began in the late 1950s, after the population of patients living in state mental institutions reached a national peak total of 559,000 in 1955.[1]

After 1955, the institutionalized population began to steadily decline largely due to the development of drugs, such as Risperidone, intended to ameliorate the symptoms of mental illness and allow sufferers to be cared for by relatives and through outpatient care programs. In 1963, in response to the burgeoning public awareness of abuses that had taken place in state-run mental institutions and with the tacit support of drug manufacturers, the Kennedy Administration unveiled the Mental Retardation Facilities and Community Mental Health Act. The Act’s purpose was to promulgate the construction of “2,000 community mental health centers by the year 1980, and thereafter build one per 100,000 population and keep it at that rate,” according to remarks made by Sen. Daniel P. Moynihan, chair of the Senate Finance Committee, in 1994. Moynihan, who had supported the Act and was present at its signing, went on to tell the Finance Committee, “But we built about 400 and then forgot that we had set out to do this….Then we stopped, but the deinstitutionalization continued, or is more likely the case, people did not go into institutions. Then a generation went by and, low and behold, we now have a problem called ‘the homeless,’ which in my state, at least, is defined as a problem which arises from the lack of affordable housing. It does nothing of the kind. It arises from a decision based on research to follow a particular strategy with respect to a particular illness, which I think we now know has a fairly steady incident in any large population anywhere. The species has this problem.”[2]

There was foreshadowing of the problems to which Moynihan referred as early as 1971, when Jerry Wiener, then the director of the Georgia Mental Health Institute’s Division of Youth, wrote to Gov. Jimmy Carter with concerns raised by the report of the governor’s Commission to Improve Services to Mentally and Emotionally Handicapped Georgians.[3]

The commission was intended to promote deinstitutionalization in Georgia. The concerns pointed out by Wiener remain relevant today and serve as reliable markers in researching deinstitutionalization’s problematic legacy and possible solutions:

  • What were the medical and scientific justifications for the deinstitutionalization movement?
  • How were censuses of institutionalized patients conducted and projections of the mentally ill population calculated?
  • What programs and funding were put in place to prepare for the impact that returning mentally ill individuals to their families and hometowns would have on relatives and communities?

Wiener asked the governor for answers and got the following response: “Your point about the difficulty in reaccepting patients from mental institutions into communities is well taken. Without decent community aftercare, prevention, and education programs, however, these difficulties cannot be studied and corrected. I, too, hope that the state will never be so callous as to release citizens from institutions who will falter in their home communities and also adversely affect the lives of other citizens.”[4]

Questioning the Medical and Numerical Justification of Deinstitutionalization

Wiener, who was also the director of Child and Adolescent Psychiatry at Emory University, questioned the science behind the Carter commission’s anti-institutional stance. He began his letter by quoting from page 14 of the commission’s report: “No emotionally disturbed child need be institutionalized in Georgia.” He then wrote “I do not know of any scientific study, statistical data, responsible body of professional opinion, or relevant clinical experience which would support this statement.” Although he agreed that community-based programs were “sorely needed” in Georgia, he warned “their availability in no way eliminates the ongoing need for high-quality, professionally staffed, diagnostic and treatment-oriented residential facilities for a significant number of Georgia’s youth. Feelings of dissatisfaction over the inadequacy of previous or existing institutional programs should not and does not lead to the conclusion that such programs are not needed.”[5]

He also believed the numbers the commission had used in compiling its report were too conservative. The commission reported that 30,000 children in Georgia “experience serious emotional disturbance.” Wiener, in calculating the incidence against the state’s census believed there were “70,000 of Georgia’s children and youth who can be expected to have either severe mental or emotional illnesses or serious developmental disturbances. An additional 130,000 can be expected to have identifiable emotional or developmental difficulties which require intervention.” In planning community services, Wiener noted, the commission should take the larger numbers into account.[6]

Wiener, significantly, took issue with the commission’s assertion that the daily population of mental hospital patients was declining as the result of community-based mental health programs. “The national experience has been that the average daily patient population and average length of stay in psychiatric hospitals have decreased steadily since the introduction of effective drug treatment beginning in the late 1950s,” he wrote. “Only recently, however, have questions begun to be raised as to the effects on the families and children of this return to or retention in the community of many still significantly disturbed adults whose overt symptoms of mental illness may be ameliorated or diluted by drug management, but whose interpersonal and/or parenting capacities may be still significantly impaired. These questions do not as yet have good answers but must be taken seriously if we are to be serious about prevention of illness in children.”[7]

Transinstitutionalization

Deinstitutionalization continued apace but a large part of it was actually transinstitutionalization.

The Community Mental Health Centers created under Kennedy’s 1963 act “had, at best, a minor impact on reducing hospital populations after 1965,” wrote mental health historian Gerald N. Grob. “Far more important were federal entitlements. The passage of Medicare and Medicaid (Titles XVIII and XIX of the Social Security Act) in 1965 encouraged the construction of nursing-home beds, and the Medicaid program provided a payment source for patients transferred from state mental hospitals to nursing homes and to general hospitals. Although the states were responsible for paying the full cost of keeping patients in state hospitals, they now could transfer them and have the federal government assume from half to three-quarters of the cost.”[8]

One such transinstitutionalized individual was William Boyd Carver Jr., a 29 year-old with cerebral palsy, a disorder involving muscle control of the limbs, mouth or tongue but not always of intellectual ability. Beginning in 1972, Carver wrote a series of letters to Governor Carter and his wife, mental health activist Rosalyn, asking, first, to have his Medicaid “switched” to a nursing home in Georgia from one in Minnesota so he would be closer to his family—at least until a place could be found for him in a “youth home” in Minnesota—and then, after residing in three nursing homes in Georgia and becoming depressed and suicidal, finally asking to be put in a mental hospital so he could be around people his own age.[9]

“Please read this and take action as soon as possible,” Carver wrote on Jan. 23, 1974. “I would like to commit to one of Georgia’s mental hospitals for psychiatry help. I have tried three nursing homes to find the answer to my problem, but fell (sic), and there isn’t any real companionship or fulfillment of life for a twenty-nine year-old adult in any of them…Can you send me somewhere for help, even if it has to be Central State Hospital, for a while, so I can be around people of my own age.”[10]

 

 

 

 

[1] United States Senate. 1994. “Deinstitutionalization, Mental Illness and Medications.” Hearing before the Finance Committee. 103rd Congress. Second Session. May 10, 1994. Washington D.C.: GPO.

Letter from Jerry Wiener to Gov. Jimmy Carter, Dec. 7, 1971, Rosalyn Carter’s Gubernatorial Special Projects and Events File, folder marked “Mental Health—Georgia Mental Health Institute,” Box 133, Carter Center Archive (CCA)

Gerald N. Grob, “Public Policy and Mental Illnesses: Jimmy Carter’s Presidential Commission on Mental Health,” The Milbank Quarterly, Sept. 2005. 83(3): 425-456

[2] U.S. Senate Finance Committee, May 10, 1994. Chairman Moynihan. P. 2-3

[3] Wiener letter to Gov. Carter, Dec. 7, 1971, Rosalyn Carter’s Gubernatorial Special Projects and Events File, folder marked “Mental Health—Georgia Mental Health Institute,” Box 133, CCA

 

[4] Gov. Carter letter to Wiener, Dec. 28, 1971, Rosalyn Carter’s Gubernatorial Special Projects and Events File, folder marked “Mental Health—Georgia Mental Health Institute,” Box 133, CCA

 

[5] Wiener letter to Gov, Carter, Dec. 7, 1971, Rosalyn Carter’s Gubernatorial Special Projects and Events File, folder marked “Mental Health—Georgia Mental Health Institute,” Box 133, CCA

 

[6] Wiener letter to Gov. Carter, Dec. 7, 1971, Rosalyn Carter’s Gubernatorial Special Projects and Events File, folder marked “Mental Health—Georgia Mental Health Institute,” Box 133, CCA

 

[7] Wiener letter to Gov. Carter, Dec 7, 1971, Rosalyn Carter’s Gubernatorial Special Projects and Events File, folder marked “Mental Health—Georgia Mental Health Institute,” Box 133, CCA

 

[8] Grob, The Milbank Quarterly, Sept. 2005. 83(3): 425-456

 

[9] Letters from William Boyd Carver Jr. Jan. 2-23, 1974, Carter Family Papers, Rosalyn Carter’s Gubernatorial Special Projects and Events File, Folder marked “Mental Health Correspondence—Metro Atlanta [1], Box 131, CCA

[10]Letters from William Boyd Carver Jr. Jan. 2-23, 1974, Carter Family Papers, Rosalyn Carter’s Gubernatorial Special Projects and Events File, Folder marked “Mental Health Correspondence—Metro Atlanta [1], Box 131, CCA

 

A brief examination of the consequences of deinstitutionalization

Mental health and public policy, Mental health funding, mental illness and public policy, Mental illness funding

By Stephanie Ramage

It is casually acknowledged in the United States that many of the homeless are mentally ill. There is also some understanding that the mentally ill became homeless because of government policies that closed mental health facilities in the 1960s, 1970s, 1980s, and 1990s. What is less understood is which policies were adopted as a result of deinstitutionalization, and how they came to be policies, and what was the reasoning behind those policies. It’s misguided to attribute the presence of the mentally ill on our streets today to milestone court cases, like the U.S. Supreme Court decision in Olmstead v. L.C. in 1999, which said patients who could be moved to community care mental health programs should be moved to them rather than remaining in institutions, or to legislation like the Omnibus Budget Reconciliation Bill of 1981, which cut federal spending on mental health programs by about 20 percent. But, in fact, deinstitutionalization was a 40-year movement that originated among psychiatric care providers who believed that tremendous progress in the development of pharmaceuticals designed to control the symptoms of mental illness would enable many of even the most seriously mentally ill to live “normal” lives in the community—either with family members, alone or in group homes—contributing positively to their own lives and the lives of those around them. As the drugs became easier and safer to use, managed care providers began approving their use in non-institutional settings. They represented a cost-savings for providers and seemed a godsend to those whose friends and family members had suffered isolation and ill-treatment in institutions. [1]

To understand why and how the government embraced the idea of deinstitutionalization in the face of pharmaceutical breakthroughs, it’s important to note that the history of mental institutions in the U.S. is a local and state history, not a federal history. Cities and states developed their own facilities for caring for the mentally ill. The first hospital built to treat both the physically and mentally ill was opened in Philadelphia in 1752, a full 25 years before independence from England. It was funded by the colonial assembly.  The first hospital built to house and treat the mentally ill exclusively was funded by Virginia’s colonial legislature and opened in 1773. And so the trend continued even after the American Revolution, with cities, counties and states raising taxes for building and operating mental institutions.[2] Over the first century-and-a-half of America’s independence many of them would become understaffed and ill-equipped as they took on the responsibility of the indigent mentally ill and their budgets proved inadequate to the task. Still, there seemed no better alternative. The drugs that would help make mental illness more manageable wouldn’t be discovered for another century.

By 1955, there were more than 559,000 people in state operated facilities.[3]

About 40 years later, when the U.S. Senate Finance Committee convened a hearing on deinstitutionalization, mental illness and medication as part of Congress’ deliberations on a national health care plan, that number had shrunk to about 85,000 according to Richard C. Surles, commissioner of mental health for the state of New York, who gave testimony to the committee.[4] The dramatic decrease had been made possible, at least in part, by the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963, which was signed into law by President John F. Kennedy.

In that Senate Finance Committee hearing in 1994, Sen. Daniel P. Moynihan (D-NY), who had been present when Kennedy signed the law and who served as chair of the finance committee, explained what he believed had happened in response to the widespread support for transitioning patients out of the state institutions: “President Kennedy’s bill specifically provided that we [the federal government] would build 2,000 community mental health centers by the year 1980, and thereafter build one per 100,000 population and keep it at that rate. But we built about 400 and then forgot we had set out to do this. The institutional memory got lost in Congress, and in the Department of Health, Education and Welfare. Then we stopped, but the deinstitutionalization continued, or is more likely the case, people did not go into institutions. Then a generation went by and, low and behold, we now have a problem called ‘the homeless,’ which in my state, at least, is defined as a problem which arises from the lack of affordable housing. It does nothing of the kind. It arises from a decision based on research to follow a particular strategy with respect to a particular illness, which I think we now know has a fairly steady incident in any large population anywhere. The species has this problem.”[5]

Without Kennedy’s planned 2,000 community health centers, the states and the federal government were forced to redefine their relationship. Before deinstitutionalization, the states’ budgets provided 96 percent of funding for the care and housing of the seriously mentally ill—after all, they had been in state owned and operated facilities. However, with deinstitutionalization the federal government began picking up more than 50 percent of the tab for care through what E. Fuller Torrey, a clinical and research psychiatrist at one of the nation’s few federally-run hospitals, St. Elizabeth’s in Washington D.C., has described as a “disordered funding system,” a mish-mash of Social Security, Medicaid, Medicare, SSDI, food stamps and HUD subsidized housing.

“This has created a gigantic fiscal carrot,” Torrey told the committee. “Providing a huge incentive for the States to empty out their state mental hospitals and providing virtually no incentive for the States to then follow these people once they leave the hospital.”[6]

States were left scrambling to find accommodations for their former charges. Some, like New York, according to Commissioner Surles, put them up in single room occupancy hotel rooms.

“At one point in the 1970s, we had over 100,000 single-room occupancy hotels in New York City alone. A third of those beds were occupied by people who had a severe mental illness,” Surles told the committee.[7]

Little changed over time. In the late 1990s, years after the Senate Finance committee tried to figure out how to fund treatment of mental illness under the Clinton Administration’s proposed national health care plan, a registered nurse researcher at DePaul University conducted a study of the homeless mentally ill, tracking 60 people from their discharge from a state mental hospital through the course of two years in community mental health. The study found that SROs (single room occupancy) hotels were the most prevalent housing available, though gentrification threatened even that. Nonetheless, the accommodations were far from ideal. The rooms were small, sparsely furnished and not usually clean—the last often as a result of the former patients’ inability to either understand or execute basic cleaning.

“How often there was hot water, how clean the facilities were, how many vermin were present, and how rowdy or dangerous the neighbors were depended on the price of the room and the client’s ability to maintain a standard of behavior acceptable to the management…,” the study’s author noted. “Trash, partially eaten food, and dirty laundry were strewn throughout the rooms, leaving little floor space for walking. The clients seemed oblivious to their housekeeping lapses, unless threatened with eviction.”

Evictions were also a part of their lives. The DePaul University study noted that the newly-transitioned mentally ill would accumulate 4.6 moves per individual per year, with an average of 2.6 months in each placement. [8]

Poverty and inability to manage daily tasks like housekeeping and laundry would emerge in yet another study in 2010, this one conducted by patients themselves with help from a professor in Yale University School of Medicine’s Psychiatry Department. Eight patients interviewed 80 other patients who were affiliated with Yale’s Program for Recovery and Community Health and the North Central Regional Mental Health Board of Connecticut. Patients told their interviewers of experiences of homelessness, including being robbed and beaten, isolation in the community, and (in the case of at least one non-homeless patient) a sense of accomplishment from learning how to do simple tasks. Many of the patients highlighted by the study referred to being overwhelmed with basic day-to-day chores and having no one responsible to whom they could turn for guidance.

Larry Davidson, a doctor in the department, noted “While the last patient we quoted may be doing his laundry by himself now, this leg of the journey comes after many years of having to rely on others to do things for him first, and then to show him how to do things for himself.”[9]

In commentary on the 2010 journal article that published the findings of the user-led research in Connecticut, E. Fuller Torrey, the same practitioner who had provided testimony to Sen. Moynihan’s finance committee, concluded: “The data summarized by Davidson and colleagues suggest that Connecticut, as one of the most highly rated states for mental illness services, is indeed merely one of the smartest kids in the class for dumb children. For half a century in the United States, we have been very effective in emptying our state psychiatric hospitals and very ineffective in providing the services needed by the discharged patients to live in the community.”[10]

 

 

 

 

[1] Richard G. Frank and Sherry A. Glied, Better But Not Well: Mental Health Policy in the United States Since 1950 (Baltimore: Johns Hopkins University Press, 2006) Digital Location 279

[2] Gerald Grob, Mental Institutions in America: Social Policy to 1875 (New York: The Free Press, 1973), p.16-26

[3] United States Senate. 1994. “Deinstitutionalization, Mental Illness and Medications.” Hearing before the Finance Committee. 103rd Congress. Second Session. May 10, 1994. Washington D.C.: GPO

[4] U.S. Senate, Finance Committee, May 10, 1994. Surles p. 13

[5] U.S. Senate Finance Committee, May 10, 1994. Chairman Moynihan. p. 2-3

[6] Ibid. Torrey, p. 20

[7] Ibid. Surles, p. 14

[8] Lin J. Drury, “Community Care for People who are Homeless and Mentally Ill,” Journal of Health Care for the Poor and Underserved; May 2003; 14 (2) p. 198

[9] Larry Davidson et al, “’I Don’t Know How To Find My Way in the World,’: Contributions of User-Led Research to Transforming Mental Health Practice,” Psychiatry 73(2) Summer 2010.

[10] Ibid. E. Fuller Torrey