In Defense of Institutions

Are institutions really that bad? If the history of people with disabilities is any indication, the answer is no.

As someone who's been studying the history of mental hospitals for well over two decades, I'm familiar with all the arguments against using institutions to house people with mental disabilities. But a glance at the history of institutions might surprise a lot of people.

Most think that criticism of institutions is a recent thing, born out of the 1960s counter-cultural attacks on traditional society. At the time, Thomas Szasz, Erving Goffman, Michel Foucault and others vilified mental hospitals as "total institutions," where inmates allegedly endured lives of ritual abuse or callous neglect.

Images of Nurse Ratched in the movie version of Ken Kesey's One Flew Over the Cuckoo's Nest (1976) have taken on a kind of iconic status, engraving in our minds the message that mental hospitals are dehumanizing places of confinement, little different than concentration camps. As the title of the 1948 Oscar-winning film stated, a mental hospital was a "snake pit."

But attacks on mental hospitals are nothing new. At first mental institutions were called "asylums," and were built with many humane motives. As country after country around the industrialized world built asylums (often at tax-payers' expense) in the nineteenth century, the belief was that people with mental disabilities would benefit from institutionalization. Free room and board, exercise, fresh air, and medical treatment in bright and spacious hospitals were deemed to be the best things for those suffering from shattered nerves or battered psyches.

If anything's responsible for institutions' bad rep these days, it's under-funding, which over time reduced the quality of care in asylums. They became over-crowded too, but that was chiefly because families came to appreciate them as a means of public welfare, a place to house a relative or friend who simply couldn't be cared for at home. Whether kin had a nervous breakdown, threw destructive and violent fits, or developed dementia, the asylum appeared to be the best alternative for families at their wit's end.

For women stressed by the day-to-day struggle to make ends meet, or enduring lives of domestic abuse, the asylum was often a place of welcome refuge. In the nineteenth century they sometimes fell under the care of asylum women physicians who provided compassionate care.
All along, the defects of institutions have attracted critics from all parts of the political spectrum. Once and awhile, a journalist would fake mental illness as a way of achieving admission to an asylum, and then write a mud-raking account of his experiences as an in-patient. By World War II, the burgeoning media were running story after story about the supposed gothic horrors of institutional life.

Then governments launched the "deinstitutionalization" movement. All of a sudden, the experts were proclaiming that people with mental disabilities did better in the "community," where they could lead lives. This theory of "normalization" soon reigned supreme, but theory and reality proved to be two very different things. People with mental disabilities repeatedly fell through the cracks of the system, and ended up on the street, unmedicated and vulnerable to both the elements and crooks who preyed on them.

So, today, our streets are littered with the countless human casualties of deinstitutionalization.
In one sense, the whole debate is moot, I suppose, since in the midst of this crippling recession the likelihood of governments spending money on mental hospital construction is as remote as Roseanne Barr writing a book on etiquette.

Still, it's important to realize that the history of asylums was not black and white. Once we understand that institutions actually helped a lot of suffering people in the past, we can better weigh the strengths the weaknesses of the next bright idea to come along in the field of mental health care.