Though it’s often said that America “closed the asylums” in the twentieth century, every state still operates at least one public mental institution. These facilities, called state hospitals, are the last stop on each state’s continuum of care for people with serious mental illness. Patients typically get admitted after an insanity plea, a declaration of incompetence, or a court finding of grave disability. Unlike patients at general hospitals’ psychiatric wards, those at state hospitals often stay for months, even years.
As an artifact of nineteenth- and twentieth-century mental-health policy, today’s state hospitals are often set on mammoth physical plants in small, rural towns; many operate on the same grounds as the old asylums. Those facilities, conceived as self-contained therapeutic farming communities for the mentally ill, downsized after the passage of the 1964 Community Mental Health Act. The vestigial population that remained behind, plus the dwindling number of patients later admitted, filled the husks of the properties, which officials rebranded as state hospitals.
Much has changed. The facilities are now much smaller—the number of public psychiatric inpatients nationally fell from more than 550,000 in 1955 to fewer than 40,000 in 2020—and their patients, on average, are much sicker, having cleared the overwhelming legal and political hurdles to institutionalization. Many once-bustling institutions are now characterized by inactivity, overmedication, and patient idleness. But it does not have to be this way.
Consider these institutions’ histories. Asylums were once entirely self-sufficient, operating their own farms, medical hospitals, restaurants, and emergency services. They often employed their patients in various activities, including agriculture, carpentry, and textiles.
But a decades-long litigation campaign directed at “institutional peonage”—unpaid labor in facilities such as hospitals and prisons—changed that. In 1973, the U.S. Court for the District of Columbia ruled in Souder v. Brennan that amendments to the Fair Labor Standards Act applied to patient workers in mental institutions. The Supreme Court reversed the ruling in 1976, but the years of litigation that preceded Souder achieved the plaintiffs’ intended effect: forcing states to shutter, or downsize significantly, their hospital farms and occupational programs.
As a result, today’s state hospital patients wander small, fenced-in wards with little meaningful activity, in what the Treatment Advocacy Center describes as “enforced idleness.” Activist attorney David Schwartz, tasked with “end[ing] institutional peonage” at the Willard State Hospital in upstate New York, couldn’t help but note the irony that facilities “full of inactive people” had a “history of providing meaningful occupation for hundreds of patients through hospital farms, orchards, cider mills, and shops.”
Though abolishing peonage had the positive result of compensating patients for their labors, its larger effect was to prompt states to close their asylum farms and, eventually, many of their asylums, rather than to pay seriously mentally ill patients for work that could be done more efficiently in the private sector.
Many patients, however, found that work meaningful. In a 1978 study of patients discharged from mental hospitals, one, Dennis, reportedly told proctors that he “would have preferred to go back” to the hospital, because there, “he had a job working in the laundry.” When New Jersey’s Allentown State Hospital downsized and closed its asylum farm following the passage of a 1974 state law banning peonage, local historian Ed Pany recalled that “[t]ears flowed down the faces of a number of state farm patients.” He marveled at “how the male patients,” in particular, “integrated themselves into a farm community.”
Nature, particularly farmwork, is restorative. That insight inspired lawmakers to place the asylums, and their state hospital successors, in the countryside. Today’s state hospital patients have often lived for decades on squalid street corners or in cramped jails and deserve better than to have that experience recapitulated in a place that, decades ago, would have been said to provide “asylum.”
Instead of resigning patients to drugged-up days on locked wards, state hospitals should reopen their farm and occupational-therapy programs, paying patients commensurate with work performed. Doing so may be costly, but improving institutional care can reduce violence on hospital wards and, eventually, violence in the community if patients are discharged. The work may have the “emphasis of a different social era,” as Schwartz put it, but the structure and dignity it provides are perennially valuable.
Photo: Massachusetts Dept. of Environmental Protection, CC BY 2.0, via Wikimedia Commons
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