After Deinstitutionalization, America's Mental Health System Struggles To Protect the Public
Decades after closing state psychiatric hospitals, the U.S. still struggles to “find a middle ground—an institutional arrangement that recognizes both the dignity of the mentally ill and the public’s right to be safe.”
One of the charming, if bizarre, discoveries I made living in New England was its constellation of splendid, thoroughly abandoned mental institutions. They occupied commanding heights in bucolic rural backwaters—fine Victorian masterpieces of red brick and turreted cupolas. The one near Danvers, Massachusetts, was perhaps the most impressive—the sheer scale and strange, unsettling quiet of it all inspired curiosity. The awe these deserted institutions inspired has never left me.
I thought of the place recently in light of the awful murder of Ukrainian refugee Iryna Zarutska by Decarlos Brown on a subway car in Charlotte, North Carolina. The assassination shortly afterward of Charlie Kirk eclipsed the headlines, but each case has a great deal to say about our national schizophrenia over mental illness.
While Kirk's murderer was clearly unstable, he showed no actionable warning signs of the violence he was about to commit. Zarutska's murderer, on the other hand, was a known quantity—a time bomb whose repeated encounters with the law painted a trajectory that could predictably end only in disaster. Brown was trapped in the liminal space between mainline criminal incarceration (where he spent time) and the psychiatric wards of yesteryear, which no longer exist. The societal question over individual liberty and social safety, however, remains.
The State Lunatic Hospital at Danvers fairly exemplifies the structural elements at play. Since the 1960s and the era of "deinstitutionalization," the United States has substantially eliminated treatment space dedicated to the care and incarceration of the mentally ill, with an estimated 64 percent decrease since 1970. Some of this decline was a rational response to advances in antipsychotic medications and moves toward "community-based" care, but much of it was about funding and politics.
The politics, in their turn, were shaped by the growing disaffection with the model of treatment these facilities could offer. Centralized psychiatric care at places like Danvers had become grossly overcrowded, and disturbing methods of treatment made everyone uneasy. Eunice Kennedy Shriver, sister of President John F. Kennedy, said of her sister Rosemary after a botched lobotomy, "Her mental capacity diminished to that of a two-year-old child, she was left incontinent and unable to speak intelligibly." Stories like these shifted public opinion. By 1963, the Community Mental Health Act devolved mental care toward local communities, and the closing of large state institutions began. By 1981, under President Ronald Reagan's Omnibus Budget Reconciliation Act, the process was effectively complete: The era of the "psychiatric facility" was over. Danvers closed for good in 1992 and was largely demolished in 2007.
These shifts had major implications—many of them good. They helped protect patients from abusive treatments and from the Dickensian nightmare that many asylums had become. But they obviously didn't end mental illness. In effect, they merely pushed the problem to less visible peripheries and increasingly depended on the criminal incarceration system to pull up the slack for those unable or unwilling to seek professional treatment. Prisons became, in effect, the nation's new asylums—only without the mandate, expertise, or resources to treat the underlying pathology.
The results are visible in tragedies like Zarutska's. Those who ride subways, walk city streets, or simply send their kids to public schools know from experience that they harbor a certain population of untreated, unstable individuals. Some are harmless eccentrics. Some are self-medicating strugglers. Still others are genuinely dangerous, propelled by paranoia or psychosis toward catastrophic acts.
This is the point where a free society faces its most uncomfortable question: How do we balance liberty with involuntary commitment? America's default in recent decades has rightly been to err on the side of liberty, a choice with noble roots but sometimes tragic consequences. We recoil from the notion of allowing the state to lock up citizens without trial. We recall the abuses of "insanity defenses" and the ease with which Soviet authorities diagnosed dissidents with schizophrenia. Our suspicion of state power is vital. But in our zeal to prevent abuse, we have stripped away tools that might, in fact, protect both the vulnerable and the innocent.
This very debate was featured in the pages of Reason, and it's evident that the "lock 'em up" or "let 'em be" camps can both find ample supporting evidence for their positions. Mike Riggs, a contributing editor at Reason, takes the firmer individualist position, writing that, "mentally ill people can be deprived of their liberty only as a form of punishment and only if they victimize someone; they cannot be deprived of their liberty to merely deliver them from temptation or risk." Libertarians, as a rule, would be inclined to agree—accepting the risk of isolated violence over systemic "preventive" incarceration. Riggs is supported by psychiatrist Thomas Szasz, who wrote in 2016 that "the overwhelming majority of mentally ill people can live okay lives outside of any institution, hopefully receiving community care if they want it. If they commit crimes they will go to prison just like anyone else."
The murder by Brown confronts us with the frightening failure of this system. Lawmakers in North Carolina have introduced "Iryna's Law" to try to fill the void caused by a justice system that has "lost institutional control" over its community. Balancing liberty and security in this situation will not be an easy task, especially amidst the heightened emotions over a heart-wrenching murder.
Other societies have attempted to strike their own balance. The Netherlands, for example, has developed a model that attempts to thread this needle more carefully. Dutch law allows for terbeschikkingstelling (TBS), a system in which courts can impose psychiatric treatment in secure facilities for offenders deemed dangerous due to mental illness. The regime is subject to judicial review and proportionality standards, but it acknowledges a simple truth we Americans seem to resist: Some people are both ill and dangerous, and society must manage that reality rather than wish it away. The Dutch experience suggests that it is possible to protect public safety without abandoning civil liberty altogether—but it is hardly perfect. My wife's good friend, a psychologist at one of these secure facilities, witnessed the horrific murder of a care provider by a psychopathic inmate. Yet the very fact that this tragedy occurred within walls designed to shield the innocent from this psychosis directly highlights the awful tragedy of the American system, which allowed Brown to prowl the North Carolina subways.
There are glimmers of reform. Some states have experimented with "assisted outpatient treatment" laws, which compel treatment without requiring long-term confinement. Others have piloted crisis-intervention teams that divert offenders toward psychiatric care rather than jail. These are steps in the right direction, but they remain piecemeal and controversial, constrained by our deep-seated suspicion of institutionalization.
Perhaps that suspicion is justified. No one, after all, wants to resurrect the abuses of the asylum era. Yet it is worth remembering that we once accepted the need for institutional care as a matter of course, and that our rejection of it was as much about cost and scandal as it was about basic principle. The empty hulks at Danvers and elsewhere stand as monuments to that choice—monuments we dare not celebrate, but whose consequences we live with every day.
The derelict asylum on the New England hillside and the violent crime on the Charlotte subway are connected. Both reflect our collective discomfort with the messy problem of mental illness in a free society. We can choose essential liberty, or we can choose safety, but giving up the former for temporary stints of the latter has, as the famous Benjamin Franklin quote goes, permanent consequences that condemn us to neither.
Unsatisfying as it feels in the heat of the moment, our challenge is to find a middle ground—an institutional arrangement that recognizes both the dignity of the mentally ill and the legitimate right of the public to be safe from clear and present harms. Other societies have shown this is possible. Ours, so far, has chosen paralysis. Until we grapple with the hard question of what we owe to the dangerously unstable, we will continue to live with headlines like Zarutska's, and with the haunted ruins of Danvers as mute testimony to our unfinished business.
