The history of psychiatric institutional care begins in the 8th Century and the Islamic world of the Middle East and North Africa. In keeping with a belief that God loved insane people, asylums that offered patients special diets, baths, drugs, music, and pleasant surroundings were established in Baghdad, Cairo, Damascus, and Fez.

Conditions in Europe were very different. Throughout the Middle Ages, the Renaissance, and the Enlightenment, mentally ill persons were subjected to horrendous conditions. For example, the Hospital of Saint Mary of Bethlehem in London , which first admitted patients with mental illness in about 1402, was infamous for its brutal and inhumane treatment of inmates. By the 16th century, its nickname – “Bedlam” – signified any asylum or person who was mad.

A relatively brief period of improved care started in the late 18th century, when Jean-Baptiste Pussin, superintendent of a ward for “incurable” mental patients at La Bicêtre hospital in Paris , prohibited beatings and released patients from shackles.

In 1793, Phillipe Pinel became chief physician at La Bicêtre, and he continued these reforms. He developed “moral treatment,” a form of care that offered patients sympathy and kindness rather than cruelty and violence.

In 1796, William Tuke established a model of compassionate care in rural – the York Retreat where people with severe mental illnesses were able to rest, talk about their problems, and work. Practices in North America followed suit and, between 1817 and 1828, a number of “modern” mental institutions opened.

This period of benevolence did not continue for long. Care in psychiatric institutions deteriorated to mere custodial functions that provided patients with the bare requirements of subsistence in environments that were generally overcrowded and unhealthy. These conditions predominated in the mental hospitals of North America and Europe from the latter half of the 19th Century until the middle of the 20th.

Deinstitutionalization in the United States

Beginning in the 1950s there was an effort throughout the to remove long-term patients from psychiatric facilities and place them in community-based treatment programs. The impetus of this deinstitutionalization movement came from a convergence of several social forces.

First, with the successes in treating soldiers traumatized by their experiences in World War II, psychiatrists become optimistic about their ability to effectively treat mental disorders outside of hospital settings.

Second, there was a growing feeling that the abusive conditions found in most state psychiatric hospitals, and the negative effects of long-term institutionalization, were at least as harmful as chronic mental illness itself. Many came to believe that the civil rights of people with mental illness were violated.

Third, fiscal conservatives in the government were concerned with the enormous expense of caring for patients in large institutions. And finally, in 1954, the discovery of chlorpromazine, the first effective anti-psychotic medication, made it reasonably possible to manage the care of persons with chronic mental illness outside the hospital.

All together, these forces brought about a dramatic shift in admission and discharge practices at state and county psychiatric hospitals. The effects of these changes can be seen in the following data: in 1955, 559,000 patients were living in state and county psychiatric hospitals throughout the country. In 1980, only 138,000 people were living in such facilities.

The Effects of Deinstitutionalization

By virtually all accounts, the deinstitutionalization movement in the has been an utter disaster. Sociologist Christopher Jencks notes that good care is expensive, whether it takes place in a hospital or in the community.

“Deinstitutionalization saves big money only when it is followed by gross neglect.” In addition, the term deinstitutionalization, as it is applied in the , is a misnomer. Dehospitalization is a more accurate way to describe what took place. While long-term patients were discharged, short-term inpatient care increased. That is, the locus of care for those suffering from chronic mental illness did not change so much as patterns of care. Many patients were merely reinstitutionalized, placed in such settings as nursing homes and board-and-care facilities. Others were relegated to temporary shelters or single-room occupancy (SRO’s) hotels.

Worst of all, the criminal justice system has, for many persons, taken on the role of the old state hospitals. Citing jail as possibly "our most enduring asylum," Katherine Briar-Lawson, Dean of the School of Social Welfare at the University of Albany , has written:

"When traditional pathways of care are blocked, the local jail becomes the recycling station for some deinstitutionalized persons. Like the old asylums, the jail increasingly functions as the one place in town where troubled persons can be deposited by law enforcement officers and not be turned away."

Recent estimates suggest that between 6 and 15 percent of those in city and county jails, and 10 to 15 percent of those in state prisons are suffering from severe mental illness. Indeed, the Los Angeles County Jail has been identified as the largest mental institution in the United States.

Used by permission of Hott Productions, Inc.

After the deinstitutionalization movement, the mentally ill sought services in the community. This marked the beginning of the church’s significant involvement in caring for the mentally ill.  In the beginning, many churches were reluctant to share their space with the severely mentally ill.  Luckily, this pattern seems to be reversing as the church begins to take an active, welcoming role in helping this population.

For information on the historical and current role of the church, see Ministry Matters.