Closure of Hospitals 

    We have come full circle from the early Nineteenth Century, when Dorothea Dix campaigned to rescue the insane from the prisons where they languished, often under shockingly inhumane conditions. Due to her work, people with mental illness were rescued from prisons to be cared for in hospitals. But today that trend has been reversed. Once again, Americans with serious mental illness are being warehoused out of sight in our prisons.

   American mental hospitals began to close their doors in the 1960’s,* first the large state hospitals and then the small community hospitals as well. By 1994, nearly half a million former patients had been sent back to live with their families. Often, their families were unable to care for them, and a quarter of a million newly-discharged patients ended up on the streets or behind bars. So many were incarcerated that jails and prisons have become our de facto mental hospitals. Today 95% of all inpatient psychiatric care in America is provided behind bars. “Deinstitutionalization,” as the movement to close these hospitals is known, came about through a political alliance of the far right and the far left.

    On the political Right, fiscal conservatives’ goal has always been to limit government spending. In 1965, the federal govern-ment abruptly withdrew its financial support for the state hospitals, as well as the small community hospitals providing psychiatric care.  This was accomplished by enactment of a little-known provision enacted when Congress established the Medicaid program.  The provision – known as the Medicaid IMD Exclusion** forbade the use of federal Medicaid dollars to pay for care in a mental hospital. This left the states and counties responsible for the entire expense. It wasn’t just the large state hospitals that were affected; no psychiatric hospital with more than 16 beds may be reimbursed by federal Medicaid funds.

    These hospitals can still take private insurance, but due to the disabling effects of untreated mental illness, those who lack adequate treatment are often unable to work. Thus, they lack private insurance and are completely dependent on Medicaid. Medicaid is crucial to the survival of any hospital that serves the public and accepts patients without private insurance. Hospital treatment for severe mental illness can mean the difference between life and death, but because of this law such treatment is specifically denied to the people who need it most. No other severe illness is subject to such discrimination.

   Theoretically, the money saved was intended to go toward funding community mental health. But there was little political will or support from taxpayers – either on the Right or the Left – to follow up on this plan, so community mental health was rarely funded. (Note: San Mateo County has been one of the exceptions; they applied available federal funds to establish and maintain a real community mental health program.)  

Public Mindset 

   The political Left campaigned along with the political Right to abolish hospital care for mental illness. At Barrington Hall in Berkeley, where I lived in 1969, we always had a few homeless people living with us. There was a sense that the street people, as we called them, were part of the revolution. They were nonconformists, our comrades in arms, even more oppressed than we were. We wanted to revolutionize a repressive society. The former hospitals symbolized that repression. I often heard the same refrain: “Mentally ill people are no more dangerous than anyone else. In fact, they’re less apt to commit acts of violence.” I took it as an indirect commentary on our discomfort with the street people who lived with us. And an acknowledgement that many of them had been patients in the newly shuttered state hospitals. People were afraid of them. I thought of my father, his violent rages and his threats to start shooting. Of course, I kept these thoughts to myself.

   Later, however, studies came out which showed that people released from the state hospitals were no more likely to commit acts of violence than others, as long as they stayed on their medication, or unless they also had problems with drugs. And if they did commit violent acts, these were mostly directed at their own family members, usually their parents or children.
In 1960 Thomas Szasz published The Myth of Mental Illness, and on the left it was fashionable to argue that mental illness was a myth: what looked like insanity was actually the sane response to an insane society. With the war in Viet Nam, and our men being sent off to fight in that crazy war, society could seem insane.

A Perception Filtered through Psychosis and Imagination

   While Szasz exerted wide influence over the intelligentsia, Ken Kesey spoke to the masses. His breakout novel, One Flew Over the Cuckoo’s Nest, was published in 1962, just at the end of the era of massive psychiatric institutions.  As Kesey explains in his preamble to the novel, his first experience of a psych ward was as a subject in the early LSD experiments at Stanford University. Every Tuesday for six months, he took his experimental dose, then spent the day in a small locked room with a window looking out onto the ward. Later, he got a job at that same hospital (the Menlo Park VA Hospital) as a nurses’ aide on the night shift. At the time, he was a graduate student at the Stanford writing program. His experiences at that hospital gave him the material for his novel.  

   But it was the film based on the book, which was released in 1975 and swept the Oscars that year which solidified the public perception of what mental hospitals were like and what patients experienced in them.

   Even if Kesey might have doubted some of the stories he heard from the patients, he had a goldmine opportunity to let his imagination – turbo-charged on LSD – dream up terrifying scenes of abuse. The hair-raising stories in that book are filtered through the psychotic perceptions of the character named Chief Bromden. Kesey is careful in the early pages of his book to demonstrate Bromden’s delusional state. In the book, we see through Bromden’s eyes how Nurse Ratchet’s arms elongate until they reach all the way across the ward, and then wrap around the hapless Black boy like a coiled rope. In Bromden’s words, “…she blows up bigger and bigger, big as a tractor, so big I can smell the machinery inside the way you smell a motor pulling too big a load.” In his mind Big Nurse is not human but a monster robot.

   Later, when Kesey was interviewed about his book, he said that the character of McMurphy (played in the film by Jack Nicholson) was a creation based on Bromden’s distorted version of reality. Unfortunately, in the movie Bromden is portrayed as shy and awkward, but completely sane. Consequently, the audience has no reason to doubt what they see on the screen. We see a lurid horror story presented as reality, a story hard to forget. 

                                                                    In that, Ronald Reagan had the ideal public relations image 

                                                                to buttress his campaign to shut down our psychiatric hospitals.   

    The reality was, however, that the Menlo Park VA, where Kesey took LSD and later worked, was and is a teaching hospital. It was and is staffed by top-notch doctors and nurses. No nurse could have gotten away with the sadistic reign of terror Big Nurse visits on her hapless patients. She would have lost her job if she tortured patients as she does in the group therapy scenes.  The electroconvulsive (shock) therapy (ECT) scenes are equally ludicrous, presented as virtual electrocution. In reality, ECT was and is done under general anesthesia; the patient has no memory of the treatment after waking up, just as you have no memory of surgery when you wake up from the anesthetic. Curare (a paralyzing agent) is administered to keep the patients from hurting themselves. So, the grand mal seizure that results from the shock is only manifest in the brain, where it has its curative effect on severe depression.

    When I was a medical student at the University of Pittsburgh in 1976, it was my job to accompany my patient for his first ECT session. I watched as he lay down and the nurse started an IV. After that, he lay perfectly still. It didn’t take six strong men to hold him down, as reenactments often portray the situation. Only a nurse anesthetist was needed to provide the respiratory apparatus to breath for him while he was under the anesthetic. But anyone who heard “shock therapy” could easily have imagined or hallucinated the terrifying scenes pictured in Cuckoo’s Nest. 

   Whether Kesey believed this version of ECT or not, filtering the scene through Bromden’s eyes freed him to portray the scene as one of pure horror. Cuckoo’s Nest matched the anti-establishment ethos of that time. It sold movie tickets and won awards. It was the heyday of Tomas Szasz and The Myth of Mental Illness. It was hip to declare that mental hospitals were “Snake Pits,” (also based on a movie of that name) and the patients in those institutions (as in the King of Hearts, a cult film at that time) were more sane than the citizens living outside.

   Since psychiatric hospitals have always operated behind closed doors, for reasons of confidentiality, there is no easy way to counter such dogma. Those of us who see mental illness up close – in our families or in our patients, or even in ourselves – might quietly chafe at this myth, but …  to stand up and declare that we know mental illness is real, through a lifetime of experience?  Or casually discuss our patients? Except for a few brave souls, we find that to be too daunting and we keep our mouths shut. So, for many people, Cuckoo’s Nest is etched in their minds as reality.

*Note: For more about the history of hospital closures, see the discussion in our Mental Health Law section. 

** For more information about the IMD Exclusion, see our discussion of IMD exclusions and waivers [to be added].