1/ This chart has been making the rounds lately, and since I am an American and have both worked in a mental hospital and been a criminal defense lawyer, I have opinions. The idea that insane people belong in institutions came under 2-pronged attack in the 1950s and 1960s. 
2/ From the left, radical psychiatrists such as R.D. Laing argued that it was society that was truly crazy, and that psychosis was a symptom of that overall situation. Hippies even embraced psychosis as a form of spiritual insight. The sociologist Irving Goffman
3/ wrote the hugely influential book "Asylums", which portrayed mental asylums as inhumane "total institutions" which broke down the humanity of their occupants. There were, of course, genuine abuses in this time period which provided grist for the mill.
4/ The other attack on mental health treatment came from the libertarian psychiatrist Thomas Szasz, who wrote a book called "The Myth of Mental Illness" arguing that mental illness was a made-up construct applied to people who simply violated social norms.
5/ I should add that both of these views are objectively false and dangerous. Schizophrenia, the illness at issue here, is not shamanic insight or a personality quirk, as anyone who has known someone with the disorder well can tell you.
6/ People suffering acute schizophrenia are unable to control their thought processes, unable to correctly interpret reality, often unable to perform basic hygiene, and are a danger to themselves (mainly) and to others. This is a terrible disability, not a choice or a gift.
7/ But in the late 1960s, a view took hold that confining people against their will for this illness was inhumane and should only be used as a last resort. The Supreme Court of the United States ruled that insane people could only be confined against their will if they
8/ were an immediate danger to themselves or others (slight oversimplification). Further, they had to be let out of confinement as soon as they were no longer *a danger* to themselves or others. This set up the infamous "revolving door": .supreme.justia.com/cases/federal/…
9/ Patient X is admitted while floridly psychotic, is stabilized on antipsychotic meds, *must* be released within 2 months, lives in the community for 4 months before going off their meds and breaking down again, and it's time for Round 2. Then round 3, 4 ad infinitum.
10/ The idea behind de-institutionalization was that "care in the community" would take the place of "total institutions". Patients were entitled to the least restrictive form of treatment. They would be placed in halfway-houses and treated with drugs and therapy.
11/ This was the idea behind Kennedy's Community Mental Health Act of 1963, part of his 'New Frontier' program. This law gave turbocharged deinstitutionalization by redirecting federal funds to community care and away from asylums. en.wikipedia.org/wiki/Community…
12/ Yet the programs were never fully-funded, and finding places in the outside world for people who were obviously mentally disturbed proved to be incredibly difficult. Who wants to live next to a half-way house full of heavily-drugged paranoid schizophrenics?
13/ So millions of people were kicked out of huge 'Kirkbride Plan' mental asylums, which were often put to other uses or just left to decay. They were placed in various group homes and half-way houses, but frequently just ran away from them. kirkbridebuildings.com
14/ to live on the street, often using drugs. Since they could not be forcibly returned to the community placement unless they were actually dangerous -- not just floridly psychotic -- they dropped out of the system except when they "decompensated" in public.
15/ Why do they go to prison? A few reasons. First of all, it is almost impossible to win an insanity defense in the USA. It's only attempted in under 1% of cases, and is only recognized in a fraction of these. Further, people in the system come to understand...
16/ that some dangerously psychotic people just need to be off the streets. Since long-term confinement in asylums is no longer an option, prison is the only choice -- at least they'll be cared for and receive some minimum level of bare-bones treatment (depending on the state).
17/ In practice, 'treatment' often means they're pumped full of drugs. Of course, prison is a terrible environment for someone with schizophrenia, and it's also dangerous for sane prisoners, since people with schizophrenia are in fact more dangerous than sane people.
18/ So the situation in the US is a product of a perfect horseshoe-theory storm of well-meaning procedural liberalism and cost-cutting at the expense of a vulnerable population with no political power. It's a huge failure. In my view, the U.S. needs to rebuild asylums.
19/ Lobotomies and involuntary electroshock are things of the past, and modern psychiatric drugs are much less debilitating. Asylums can be run humanely and transparently. But as long as the Supreme Court interprets the constitution in such a way as to make long-term
20/ confinement impossible, the problem is very hard to solve. I think the modern Court should revisit its decisions from the 1970s. Given its present ideological orientation, it just might do that. My fingers are crossed.
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