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.
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.
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).
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