From the Snake Pit to the Supreme Court: the Collapse of the Insane Asylum in Mid-20Th Century America

From the Snake Pit to the Supreme Court: The Collapse of the Insane Asylum in Mid-20th Century America

Lauren Amos Advisor: Dr. Steven Noll

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Acknowledgements

My sincerest thanks to Dr. Noll, who let me borrow all of his books and take up all of his office hours. Thank you for introducing me to Phi Alpha Theta, the students at Sidney Lanier, and the entire field of disability history that I didn’t know existed.

Thank you to my parents, friends, and Michael, who had to listen to me talk about asylums for a year and read countless drafts and re-drafts. A special thanks to Colleen, who let me stay at her house while I visited the Tallahassee archives.

Lastly, I would like to thank the University of Florida History Department for the best undergraduate major I could have asked for, and a wonderful four years.

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Table of Contents Introduction: A Predictable Pattern ...... 4 Chapter 1: Shaping the Stigma ...... 7 Chapter 2: Common Oversimplifications for Deinstitutionalization ...... 13 Chapter 3: An Internal Attack on Psychiatry ...... 16 Reform Rhetoric from the 1890s-1950s ...... 16 The Rise of Anti-Psychiatry Literature ...... 25 Chapter 4: External Pressure from the Civil Rights Movement ...... 44 Changing the Strategy of Reform ...... 44 Personal Connections to the Civil Rights Movement ...... 48 Chapter 5: Two Movements Intersect through Bruce Ennis ...... 55 Conclusion: Why Combination was Key ...... 65 Epilogue: Where Are We Now? ...... 68 References ...... 74 Primary Sources ...... 74 Secondary Sources ...... 77

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Introduction: A Predictable Pattern

In 1843, Dorothea Dix, “the apostle of the insane,” wrote the following to the

Massachusetts legislature:

I come to present the strong claims of suffering humanity. I come to place before the Legislature of Massachusetts the condition of the miserable, the desolate, the outcast. I come as the advocate of helpless, forgotten, insane and idiotic men and women … of beings wretched in our prisons, and more wretched in our almshouses … I proceed, Gentlemen, briefly to call your attention to the state of insane persons confined within this Commonwealth in cages, closets, cellars, stalls, pens: chained, naked, beaten with rods, and lashed into obedience!1

Appalled that the mentally ill were being kept in prisons and poorhouses, Dix went on to found more than 30 mental hospitals across the United States.2 Yet when making a second and third tour of the country, she found that many of the hospitals she established herself were plagued with the same suffering and neglect she so vigorously condemned a decade before.3 She embarked on another campaign of reform, this time one of improving her own hospitals.

In 1887, investigative reporter Nellie Bly went undercover and committed herself to the

Blackwell Island Insane Asylum for ten days, detailing every abuse she saw in the “human rat- trap.”4 Her report of the brutality, cruelty, and neglect she experienced first-hand at Blackwell launched a grand jury investigation. The grand jury condemned the conditions they saw, increased the budget, and vowed to have more detailed examinations in the future.

In 1908, former mental hospital patient Clifford Beers published a book imploring

Americans to aid the mentally ill he saw “abandoned to filth and unbelievable misery.”5 He sought to improve the situation of the “helpless thousands” who suffered “needless abuse” in the

1 Albert Deutsch, "Dorothea Lynde Dix: Apostle of the Insane," The American Journal of Nursing 36, no. 10 (1936): 987-97, doi: 10.2307/3413570. 2 id 3 Ivan Belknap, Human Problems of a State Mental Hospital (New York: Blakiston Division, 1956), 14. 4 Nellie Bly, Ten Days in a Mad-House (New York: Ian L. Munro Publisher, 1887). 5 Clifford W. Beers, A Mind that Found Itself: An Autobiography (Garden City: Doubleday, 1908). 5 nation’s asylums.6 His impassioned plea, supplemented by graphic descriptions of his own time as a patient, produced a mental hygiene movement that momentarily brought the mentally ill into the spotlight.

In 1947, author Frank Leon Wright Jr. published a book one reviewer called, “So forceful and graphic, it cannot fail to shock us, to awaken us, to impel us to action.”7 The book consisted of over 2,000 reports from conscientious objectors working in mental hospitals during the

Second World War, who were sure that their exposés would shake the American public out of apathy.

From Dix to Wright, over 100 years had passed and dozens of reformist exposés published. Yet when read side by side, the two works bookending this period could easily pass as a single text. In fact, the publications of Dix, Bly, Beers, Wright, and dozens of other advocates for the mentally ill are so similar that readers could easily believe the authors were contemporaries, rather than spread over a century. The problems uncovered year after year were so persistent, so unchanging, that each round of exposés seemed the same as the last. All condemned the overcrowded, unsanitary, and inhumane conditions of American mental hospitals, and passionately called for reform. Each activist spoke with righteous conviction, sure that they were the crusaders the mentally ill so desperately needed. They were certain that with just a little more money, some slight building renovations, and a few more attendants, they would finally reform the hospital system for good. All fell far short of their goal, yet it did not stop the next generation from attempting the same futile task. A predictable pattern emerged.

Horrific conditions were revealed by some well-meaning activist, and public outcry drove a

6 id 7 Frank L. Wright, Out of Sight, Out of Mind ... A Graphic Picture of Present-Day Institutional Care of the Mentally Ill in America, Based on more than Two Thousand Eye-Witness Reports, (Philadelphia: National Mental Health Foundation, 1947), ix. 6 brief, intense period of reform. Once the public felt satisfied that they had “fixed” the problem and done their civic duty, interest quickly died, hospitals were neglected, and conditions rapidly deteriorated back to what they were before reforms were implemented. A new generation of reformers continued the cycle, writing new exposés on the same poor conditions.

The familiar pattern seemed to start up again in the 1960s, with a new round of literature condemning asylums. In many ways, these mid-1960s pieces tread familiar ground. There was nothing particularly unique about the circumstances documented or the photographs published.

However, a subtle new nuance gained popularity. These exposés and reports uncovered more than dirty floors and subpar meals. Critics started condemning the entire concept of asylums, rather than focusing solely on the poor conditions inside them. Then, in stark contrast to years past, no widespread reform effort followed these exposés. Instead, over the next decade, the asylum model was abandoned altogether. Public mental hospitals were emptied en masse, and by

1980 most states adopted deinstitutionalization as their official public policy. A 100-year old pattern was suddenly broken.

For more than one hundred years, the medical and lay communities tried to improve the mental hospital system. Then in the 1960s, an almost unanimous consensus emerged that it was irredeemable. By the 1980s, asylums were all but extinct. How did an institution so firmly embedded in American society suddenly crumble in less than 20 years? What factors made this time period so unique that it caused the United States to abandon a model it had aggressively expanded for over a century?

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Chapter 1: Shaping the Stigma

To fully comprehend the gravity of the changes that occurred in the 1960s, it is important to understand the historic public perception of the mentally ill. Public perception has played a crucial role in how the mentally ill were treated, and much of the underlying stigmas found in the mid-20th century can be traced back to the roots of the public mental asylum.

Early American reactions to mental illness stemmed from European predecessors. In the

17th-century, the European medical community held the belief that health, both mental and physical, was the result of a balance between man and the natural law. Madness was not accidental, but could only result from willfully breaking nature’s rules. As such, the mentally ill were seen as equivalent to criminals: both groups made conscious, purposeful decisions to violate the natural law.8 Mental illness became strongly associated with immorality and vice, and this stigma traveled with European settlers to America, where it was disseminated by influential ministers such as Cotton Mather.9 Yet despite fear and prejudice of the mentally ill, a formalized system of control was not adopted until the 1850s. Colonial America consisted mainly of family units scattered throughout rural communities. By 1790, there were only six true “cities” of 8,000 or more residents. In such a dispersed society, mental illness was considered an individual problem to be managed by family, neighbors, or friends. Specialized institutions were not needed to handle the relatively small, scattered number of “distracted” and “lunatic” men and women. In fact, colonial society was so spread out that many individuals’ only exposure to mental illness would be the “town fool” or an ill relative. Unless the mentally ill noticeably threatened public

8 Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason (New York: Pantheon Books, 1965). 9 Gerald Grob, The Mad Among Us: A History of the Care of America’s Mentally Ill (New York; Free Press, 1994), 4. 8 safety, they lived freely in the community, cared for by family or neighbors.10

Only when the Industrial Revolution spurred rapid urban growth did the mentally ill become visible enough to generate concern. By 1850, growing urban populations forced significant quantities of people into close proximity with one another. Concentration into cities led to considerably more citizens coming in contact with the mentally ill. Concurrently, the

Industrial Revolution moved the locus of work from the homestead to the factory. This relocation weakened the family unit, transferring the responsibilities previously associated with the household (such as educating children, caring for the elderly, and caring for the mentally ill) from the family to the community. Families became reliant on public institutions for these tasks.

The increased concentration of the mentally ill, combined with the shift in responsibility for such individuals, fostered the sense that traditional, informal reliance on family members and neighbors was no longer adequate.

An increase in public concern about security prompted large cities to create welfare institutions such as almshouses to house a variety of dependents.11 The mentally ill were kept in these public charity houses along with other dependent categories of individuals like the elderly, infirm, physically disabled, developmentally disabled, paupers, and unemployed immigrants.

Almshouses were also frequently used as prisons to house vagabonds, prostitutes, and criminals, bolstering the strong association between the mentally ill and criminals.12 Welfare institutions became undifferentiating dumping grounds, imposing the same broad categories of “dependent” and “deviant” on a wide variety of disparate groups. Placement in almshouses strengthened the association between the mentally ill and dependents and deviants. This double association meant

10 id 7 11 id 17 12 id 51 9 that the mentally ill were not only considered part of the dangerous, criminal faction, but also part of the dependent sector draining the community. This combination cultivated an overarching, pervasive fear of the mentally ill and the threat they constituted to “regular” society.

As American society grew, anxiety over all “dependents” and “deviants” intensified, even as the mentally ill were physically separated from other stigmatized groups. In the late 18th century, Frenchman Philippe Pinel and Englishman William Tuke advanced the theory of “moral therapy,” which contended that segregation of the mentally ill was key to their recovery. Only in a “well-ordered asylum,” isolated from the rest of society, could the mentally ill be subjected to a strict regimen to “internalize the behavior and values of normal society, and thus promote recovery.”13 Based on Pinel and Tuke’s philosophies, asylums devoted exclusively to the care and treatment of the insane began to open. In 1774, Virginia opened the first public mental hospital, the Virginia Eastern Asylum. By 1822 it was followed by four more institutions, the

McLean Asylum, Friends’ Asylum, the Hartford Retreat, and the Bloomingdale Asylum. In

1843, activist Dorothea Dix began her 30-year crusade to remove the insane from prisons and poorhouses. She was largely successful, and by the 1860s a public asylum dedicated solely to the insane opened in virtually every state.14

Advocates for the mentally ill like Pinel, Tuke, and Dix genuinely believed the rise of asylums was a triumph of humanity and compassion. Dix called the asylum a symbol of “modern civilization,” and her contemporaries agreed that it was an indisputable improvement for the mentally ill.15 However, despite the utopian sentiments surrounding new asylums, the movement of the mentally ill away from almshouses should not be confused with an improvement of their

13 id 27 14 id 48 15 Andrew Scull, Madness in Civilization: A Cultural History of Insanity (Princeton: Princeton University Press, 2015), 198. 10 standing in society. Moral therapy may have rationalized the isolation of the mentally ill in euphemistic terms, but they were still irrevocably linked to undesirables such as criminals and the poor. Vague fears of their deleterious effect on “normal society” persisted.

This association received scientific backing with the advent of Social Darwinism.16

Beginning in the late 19th century, Social Darwinism acquired a widespread and enthusiastic following as countless studies seemingly verified a causal link between mental illness and crime, poverty, and vice.17 This negative association only grew as financial crises and explosive population growth worsened throughout the late 19th century. Decades of economic depression, rising levels of violence, and growing class and social conflicts exacerbated an already pervasive fear of societal degeneracy.18 Asylum populations skyrocketed as the medical community and the public, supported by pseudoscience, rushed to put away the “deviants” and “dependents” responsible for society’s ills. Inpatient populations grew from 74,028 patients in 189019 to

187,791 patients in 1910, and to 425,000 patients in 1940.20

The progression of Social Darwinism into full-blown eugenics was an additional indicator of the terror the mentally ill instilled in the public. Eugenics developed in 1865, when

Francis Galton proposed that his half-cousin Charles Darwin’s theory of “artificial selection” could also be applied to humans. Desirable traits could be magnified, and undesirable traits eradicated.21 Following this train of thought, Galton believed the mentally ill and mentally

16Diane B. Paul, “Darwin, Social Darwinism, and Eugenics,” Cambridge University Press 2006, 229, http://www.dianebpaul.com/uploads/2/3/2/9/23295024/darwin_social_darwinism_and_eugenics.pdf 17 Steven A. Farber, “U.S. Scientists’ Role in the Eugenics Movement (1907-1939): A Contemporary Biologist’s Perspective,” Zebrafish, 2008 Dec: 5(4): 243–245, doi: 10.1089/zeb.2008.0576, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2757926/ 18 Grob, The Mad Among Us, 159 19 Beers, A Mind that Found Itself, 342 20 Grob, The Mad Among Us, 166 21 Francis Galton, “Hereditary Talent and Character,” MacMillan’s Magazine 12, (1865): 157-166, 318- 327, http://psychclassics.yorku.ca/Galton/talent.htm 11 handicapped represented the “inferior” portions of the human race that would have been eliminated in nature. Darwin himself agreed to a certain extent, and wrote in Descent of Man that only man was “so ignorant as to allow his worst animals to breed.” 22 Following Darwinian logic, the only way to advance the human race was to artificially eliminate undesirable traits.23

Beginning in 1907, states began to pass laws providing for the mandatory sterilization of anyone confirmed to be mentally ill. The same law also mandated the sterilization of criminals, the developmentally disabled, and rapists, revealing the continued association of the mentally ill with the societally dangerous. Between 1907 and 1940, approximately 18,500 patients with a mental illness were forcibly sterilized in mental hospitals.24

Studies publicized by Social Darwinists and Eugenicists seemingly provided scientific confirmation for what many people already believed: the mentally ill were to blame for society’s decline. 25 The stigma cultivated in 17th century Europe and strengthened by almshouses had not disappeared by the mid-20th century. Instead, it was nourished by fear and prejudice, and resulted in conscious and unconscious rejection of the mentally ill from the community.

In some ways, this rejection is understandable. Individuals with mental illnesses act in ways that are perfectly rational to themselves, but may appear bizarre and sometimes frightening to people around them. In fact, a study in 1964 determined that the level of rejection for the mentally ill appeared to be based on “how visibly the behavior deviated from customary role- expectations, rather than on the pathology from a mental-hygiene point of view.” In other words,

22 Charles Darwin, The Descent of Man, and Selection in Relation to Sex, (Princeton: Princeton University Press, 1981), 168, https://teoriaevolutiva.files.wordpress.com/2014/02/darwin-c-the-descent-of-man-and- selection-in-relation-to-sex.pdf 23 Paul, “Darwin, Social Darwinism, and Eugenics,” 226 24 Grob, The Mad Among Us, 161 18,500 patients is the “official” number of sterilizations that occurred in state hospitals, however the real number is probably much higher. 25 Paul, “Darwin, Social Darwinism, and Eugenics,” 229 12 if a person with a mental illness’s actions still aligned with social standards, they were less likely to be rejected. Only when behavior significantly deviated from the norm did rejection occur.26

Fear stems from misunderstanding, and the inability of “normal” society to understand and relate to the behavior of the mentally ill was (and continues to be) at the root of their rejection. Richard

Neutra, an architect who studied Freud and incorporated psychology into his building plans, explained,

“It is difficult to empathize with the mentally ill. It is unnatural, even impossible, to share the feelings of someone who does not talk about the same subject at the end of a sentence as he did at the beginning, who sees and responds to things we do not see, whose mood, reason and very identity may change from moment to moment. These unfortunate people are uncanny, disconcerting, and inevitably alien to us. They invite rejection.”27

A report commissioned by the United States Congress in 1961 similarly concluded, “Mental illness is different from physical illness in the one fundamental aspect, that it tends to disturb and repel others rather than evoke sympathy and desire to help.”28 The report actually designated societal rejection as the main reason asylums continued to exist, despite decades of recorded atrocities. The mentally ill were so dehumanized and rejected from “normal” society that it was deemed acceptable to isolate them in dilapidated warehouses, far from where they would do any harm. The unique stigmatization against the mentally ill provides a partial explanation of why society was so reluctant to abandon the asylum model. It flourished despite wave after wave of damning exposés, and patient populations rose until the mid-1950s.

26 Derek L. Phillips, "Rejection of the Mentally Ill: The Influence of Behavior and Sex," American Sociological Review 29, no. 5 (1964): 687, http://www.jstor.org/stable/2091418. 27 Morton Birnbaum, “The Right to Treatment: Some Comments on Its Development,” in Medical, Moral, and Legal Issues in Mental Health Care, ed. Frank J. Ayd (Baltimore: Williams & Wilkins, 1974), 108. 28 Joint Commission on Mental Illness and Health, Action for Mental Health: Final Report of the Joint Commission on Mental Illness and Health 1961, (New York: Basic Books, 1961), xxix 13

Chapter 2: Common Oversimplifications for Deinstitutionalization

In 1955, mental hospital populations peaked at 559,000 patients, then rapidly began to decline.29 By 1986, only 119,000 patients resided in mental hospitals, a decrease in population of more than three-fourths.30 This dramatic drop in patient populations is often attributed to the invention of tranquilizer drugs in the early 1950s. Tranquilizers such as Chlorpromazine

(marketed publicly as Thorazine) swept the country, largely replacing electroshock therapy and hydrotherapy as methods of medical treatment. Thorazine was hailed as a panacea for mental illness, and doctors were optimistic that all but a few mentally ill patients would be cured. These predictions were seemingly given legitimacy when patient populations decreased for the first time in 1955, suddenly reversing a century-long trend. Because the introduction of Thorazine and other drugs occurred so closely with a sudden decrease in asylum populations, it is tempting to attribute the latter to the former.

However, as historian Andrew Scull pointed out, if the formula was truly as simple as drugs equal deinstitutionalization, then the French (who invented Chlorpromazine), Germans,

Italians, Dutch, Spanish, Swedes, and Finns would have also experienced rapid deinstitutionalization. Instead, it took another quarter of a century for mental hospitals to close in

Europe.31 Additionally, empirical studies examining the correlation between drug use and hospital stay actually found that drug treatment was associated with longer hospital stays.

Furthermore, mental hospitals that treated the highest percentage of patients with Thorazine had lower discharge rates than other hospitals whose usage of the drug was lower. The introduction of Thorazine undoubtedly allowed for the release of a select number of patients who responded

29 Grob, The Mad Among Us, 49 30 id 291 31 Scull, Madness in Civilization, 368 14 positively to the drug. However, once this one-time drop occurred and all patients who responded positively to Thorazine were released, no further drop in population occurred. 32 A variety of scholars have all come to conclude that the influence of new drugs on deinstitutionalization was at best “indirect and limited.”33 Drugs alone were not enough to produce a deinstitutionalization movement.

Another common explanation given for the decline of the asylum was the development of

Medicare. In 1965, as part of this federal program, government regulations gave states more money if elderly patients were sent to nursing homes instead of state hospitals. Monetary incentives led to a sizeable movement of geriatric patients from mental hospitals to nursing homes, causing another sharp drop in patient populations. However, similar to Thorazine, the introduction of Medicare created a one-time drop that only affected a certain subgroup of patients. Once geriatric patients (who arguably were not mentally ill in the first place, simply senile) were relocated, no further drop in population occurred. Thorazine and Medicare allowed for the release of certain patients, but neither affected a much larger, core group of patients who were chronically and persistently ill.

More importantly, neither drugs nor Medicare diminished society’s faith in the asylum model. While hospital populations began to decline in 1955, hospital admissions continued to climb. More and more patients checked into asylums every year until the early 1970s,34 indicating an unabated faith that the proper place for an individual with a mental illness was inside an asylum. Steady or rising admissions meant the asylum was still seen as the predominant way to control and treat the mentally ill, and its place in society was secure.

32 Grob, The Mad Among Us, 291 33 Scull, Madness in Civilization, 369 34 John A. Talbott, The Death of the Asylum: A Critical Study of State Hospital Management, Services, and Care (New York: Grune & Stratton, 1978), 39. 15

Only in 1972 did hospital admissions reverse and begin to decline, signifying doubts in the asylum model’s legitimacy.35 The reversal in admission trends was accompanied by a third wave of patient discharges. This third wave was much different than the prior two caused by

Thorazine and Medicare respectively. It was not a one-time release of a select group. Instead, long-term, chronically ill patients in younger age groups were indiscriminately discharged in large numbers. Admission numbers and inpatient populations dropped steadily well into the 21st century. Neither Thorazine nor Medicare can explain the reversal of admissions, nor the dramatic and sustained emptying of asylums. Drugs did not suddenly become more effective fifteen years after their introduction. Medicare had already moved most of the elderly population out of asylums and into nursing homes.36 Attributing the complete collapse of the asylum system in the

1970s to either of these causes grossly oversimplifies the matter.

A much more complex interplay of forces was occurring, and the rise of two seemingly separate movements had a far greater impact on asylums than Thorazine or Medicare. First, in the 1960s, a group of authors led an internal attack against psychiatry. They challenged many of the discipline’s core tenets, and questioned for the first time whether the asylum itself could be a flawed concept. Second, beginning with Brown v Board of Education in 1954, African-American activists sparked a national atmosphere of change, and a widespread reevaluation of rights. The

Civil Rights Movement produced a variety of external forces on the asylum system, undermining the legality, constitutionality, and morality of involuntary civil commitment. The intersection of these two distinct movements triggered deinstitutionalization, not the simple introduction of drugs or the movement to nursing homes.

35 id 36 Scull, Madness in Civilization, 368 16

Chapter 3: An Internal Attack on Psychiatry Reform Rhetoric from the 1890s-1950s

Widespread acceptance in the 1960s that asylums as a system were flawed provided the theoretical backbone of deinstitutionalization. Until that time, the state hospital model was so firmly embedded in American culture that its existence went unquestioned. Largely because of the deep-rooted stigmas discussed in Chapter One, it went without saying that “crazy people” belonged locked up in an asylum far away from “normal” society. Atrocious conditions documented by social activists were seen as isolated incidents caused by lack of funds or poor management, not symptoms of a broader problem. Stigma and fear surrounding the mentally ill, combined with the longevity of the asylum tradition, fostered an atmosphere where it went presumed that asylums could and should be reformed. A survey of pre-1960s exposés reveals the depth of these two assumptions.

Dorothea Dix, the quintessential crusader many associate with the mentally ill, laid the foundation for later exposés with her 1843 appeal to the Massachusetts legislature. Dix did not technically embark on a mission to reform asylums, since most people with a mental illness were still kept in almshouses and prisons. Instead, she made it her mission that the insane be given their own institution, apart from the poor and criminal. Dix’s campaign was a sincere attempt to alleviate the suffering she saw. But by spending all of her considerable energy urging states to build asylums, Dix inadvertently narrowed the range of options for helping the mentally ill. She concentrated attention solely on the asylum model, precluding the consideration of any other solution. The debate became how to build the best asylum, not whether asylums were the best choice to begin with. Dix’s intentions were well-meaning, but her single-minded focus on asylums helped establish their status as the default method for handling the mentally ill. Later reforms would reinforce this perception, adopting Dix’s assumption that confinement in mental 17 hospitals was the only viable solution for the mentally ill.37

The first true reform effort targeting mental hospitals occurred in the Progressive Era. In

1887, Nellie Bly wrote the first widely-read exposé of an asylum, Ten Days in a Madhouse. She described patients being denied water by cruel nurses, being beaten by other patients and nurses alike, and even dying after being forced into a cold bath for hours on end.38 Bly’s description of the patients and conditions in New York City’s Blackwell Asylum was intentionally written to be sensationalistic and heart-wrenching, but she also seemed to genuinely care for the women trapped in this “Chamber of Horrors.”39 Yet despite the overwhelming, pervasive problems she witnessed, at the end of her exposé Bly seemed placated by the fact that more money had been allocated to the asylum. She proudly informed readers that as a result of her book, the City of

New York allocated a million more dollars per year for the care of insane. She did not express dismay that the “human-rat trap” was still functioning, and did not rail against the continued confinement of women who were sane enough to know they were being “imprisoned.”40 Instead, she had the “satisfaction” that the “poor unfortunates” she spent ten days with were better off because of her work, even if they were still in the asylum.41 Because of her faith that the asylum system could improve, Bly equated more money with better treatment. She considered her work a success not because it shut down Blackwell’s Asylum, but because it led to reform.

Two decades later, Clifford Beers revived public interest in the mentally ill with his 1908 autobiography, A Mind that Found Itself. He prefaced his work with the assurance that the

“majority of insane patients in this country are now treated with a consideration which amounts

37 Scull, Madness and Civilization, 198-199 38 Bly, Ten Days in a Mad-House, Chapter 14 39 id Chapter 15 40 id Chapter 11 41 id Introduction 18 to kindness.”42 His words confirmed his belief that humane asylums not only existed, but constituted the majority. He reassured readers that it was only the minority of patients being subjected to abuse, and he was “sure” that with his proof, the situation would be corrected.

Beers’ account included being beaten by attendants,43 restrained in muffs and straitjackets,44 and being kept in solitary confinement in a padded cell he called a “vile hole.”45 He described being starved for weeks,46 living in filthy, unheated cells,47 and watching attendants brutally choke fellow patients.48 But his experience did not weaken his belief that asylums were redeemable. He explicitly stated that one of his goals in writing his book was to rouse the rich, prompting them to financially support the state’s “model institutions” where diseases could be cured with

“maximum efficiency.”49 To Beers, the abuses he witnessed could quickly be remedied with increased funds.

For a time after Beers, the Great Depression and World War II diverted attention from state hospitals. As a result, the majority fell into severe neglect. Asylum conditions were disregarded by the public until the late 1940s, when conscientious objectors produced a massive wave of magazine articles, newspaper articles, and books. Conscientious objectors, or COs, refused to participate in military service due to pacifist beliefs. Instead, they were allowed to serve their World War II draft by working in prisons, in mental hospitals, or on various public projects. Approximately 3,000 COs worked in mental hospitals around the country. Most were deeply religious, and as such were appalled at the conditions and abuse they encountered. Frank

42 Beers, A Mind that Found Itself, 2 43 id 107 44 id 42 45 id 133 46 id 159 47 id 134 48 id 170 49 id 5 19

Leon Wright Jr. compiled the reports of over 2,000 outraged COs in his book Out of Sight, Out of Mind.50 The COs reported alcoholic attendants,51 decrepit institutions that were falling apart,52 and patients who were forced to do hard manual labor without compensation or breaks.53 Many reports revolved around abusive “bughouser” attendants who seemed to get cruel enjoyment out of beating patients, and who viewed violence as the only way to keep patients in check.54 Yet despite the wide-spread problems encountered by thousands of COs, Wright spent his last chapter urging the public to pass legislation and raise money to improve asylums.

Another key text of the period was Albert Q. Maisel’s Life magazine article, “Bedlam

1946.”55 Maisel’s text was a scathing exposé detailing beatings, deaths, starvation diets, and severe overcrowding in dilapidated “firetraps.”56 Maisel lambasted current asylum conditions, but also provided hope of their viability. He went on to detail Ohio’s reform of mental hospitals, led by Dr. Dores Sharpe (a church leader) and Walter Lerch (a newspaper reporter). He ended his report with the optimistic statement, “Given the facts and given leaders of the caliber of Sharpe or Lerch, the people of any state will rally, as have the common people of Ohio, to put an end to concentration camps that masquerade as hospitals and to make cure rather than incarceration the goal of their mental institutions.”57

The last and arguably most important exposé of the 1940s was by progressive journalist

50 Wright, Out of Sight, Out of Mind, 16 51 id 24 52 id 84 53 id 119 54 id 34-39 55 Maisel’s title refers to the infamous Bethlem Royal Hospital in London. Founded in 1247, the asylum gained notoriety for its cruelty, squalor, and neglect. Over time, “Bethlem" was corrupted to “Bedlam,” which became synonymous with chaos, confusion, and madness. Bedlam is still open today, making it the oldest continuously-running mental hospital in Europe. 56 Albert Q. Maisel, “Bedlam 1946,” Life Magazine, May 1946, 102, http://mn.gov/mnddc/parallels2/prologue/6a-bedlam/bedlam-life1946.pdf 57 id 118 20

Albert Deutsch. Published in 1948, his book The Shame of the States extensively documented conditions in two-dozen hospitals in a dozen states. Deutsch reported patients sleeping in filth,58 starving,59 and everywhere he looked he found “doubt [and] despair … beyond compare.”60 Like

Maisel, he compared the hospitals to London’s notorious Bedlam.61 His graphic account was the most horrific, terrifying description of mental hospitals yet published. However, like other authors, he blamed most of the problems on a lack of funding. He concluded that the “basic problem” behind overcrowding and low-quality attendants was poor wages. He criticized the cheap food and deteriorating building conditions, and denounced Pennsylvania and Ohio for having surplus treasuries yet spending so little on public hospitals.62 Deutsch ultimately attributed the conditions he witnessed to “indifference and niggardliness,”63 not any structural problems within the asylum itself.

Despite contextual and stylistic differences, the majority of exposés before 1960 saw underfunding as the core problem plaguing asylums. Bly was vague on what specific issues she hoped the increased budget would fix, but was confident “conditions” overall would improve.

Beers held that the “central problem” of hospitals was the elimination of physical abuse and non- restraint, which could also be solved by allocating more funds. Higher salaries would attract more sympathetic and more qualified attendants, and improve the patient to staff ratio.64 Better funding would also ensure accountability, and that that non-restraint became the “watchword” of hospitals.65 Maisel called on states to be more like Ohio, which dramatically improved its budget

58 Deutsch, Shame of the States, 42 59 id 61 60 id 73 61 id 106 62 id 45-47 63 id 99 64 Beers, A Mind that Found Itself, 244 65 id 140 21 and successfully “eliminated” many of the worst abuses.66 Wright absolved hospitals of most blame, as they were “hamstrung by ‘economy-conscious’ politicians."67 Without fail, authors before the 1960s were certain that increasing hospital funding would fix the problems they saw.

Even publications that were not strictly exposés established the theme that underfunding was the root of asylum problems. The 1946 novel The Snake Pit was sold as fictional literature, and author Mary Jane Ward initially denied that the book was based on any real experiences.68

Nonetheless, the critique of asylum life was obvious. The story followed a young housewife named Virginia Cunningham as she navigated through her mental illness and time in a mental hospital. Cunningham was repulsed and frightened by the insane asylum she found herself in, and the conditions under which patients were kept. She compared the smell to a zoo,69 the food inedible and disgusting,70 and her “occupational therapy” consisted of laboriously polishing floors.71 Cunningham’s most recurring complaint was the overcrowded nature of the hospital.

She lamented, “There wasn’t enough of anything at Juniper Hill. Not enough doctors, not enough nurses, not enough food, not enough covers … not enough sheets and not enough pillow cases …

There were not even enough beds. There wasn’t enough of anything but patients.”72

The film version of the Snake Pit released two years later portrayed similarly grim conditions inside the asylum, paying special attention to the chaos and pandemonium that

66 Maisel, “Bedlam 1946,” 116 67 Wright, Out of Sight, Out of Mind, 129 68 Margaret McAllister, “Looking Back to See Ahead: Reassessing The Snake Pit for its Gothic Codes and Significant,” in Peer Reviewed Proceedings: 6th Annual Conference, Popular Culture Association of Australia and New Zealand, ed. Philip Mountford, (Wellington: PopCAANZ, 2015), 84-94, http://popcaanz.com/conferenceproceedings-2015/. Ward later admitted that the book was based on her time in Rockland State Hospital in Orangeburg, New York. 69 Mary Jane Ward, The Snake Pit (New York: Random House, 1946), 18. 70 id 46 71 id 103 72 id 253 22 occurred when dozens of patients were crowded in a day room for hours on end.73 Yet despite the dismal portrayal of asylums in the movie, publicity statements from 20th Century Fox during and after the film’s release boasted that twenty-six states had enacted reforms because of the movie, not that any hospitals had shut down.74 Literature about mental hospitals was not meant to dismantle the system as a whole, question the system’s feasibility, or provide alternative solutions. Instead, the authors wrote with the intention of fixing the asylum system so it could achieve its true potential. They were certain that a well-run, therapeutic, even pleasant hospital was not only realistic, but inevitable if certain problems were simply rectified. Ward’s book and the associated film were wildly popular, and reached a larger audience than most exposés.

Viewers absorbed the notion that the only thing hindering hospitals was a lack of funds, reinforcing their faith in the asylum model. Between exposés reaching the medical community and popular literature such as The Snake Pit reaching the lay community, by the late 1940s

American society was still being told that asylums could be reformed.

As important as the belief that hospitals could be fixed was the belief that hospitals should be fixed. The exposés mirrored the public’s belief that the best possible place for the mentally ill was inside asylums, even if they were plagued by atrocities. Dix initiated this trend by demanding the building of institutions dedicated solely to the confinement of the mentally ill, rather than demanding the mentally ill be released from confinement altogether. Despite his horrific time in an institution, Beers asserted that hospitalization was the “best possible thing that

73 The Snake Pit, Directed by Anatole Litvak (1948: Los Angeles, CA: 20th Century Fox), 1:47:00- 1:49:30. 74 Nick Clooney, The Movies that Changed Us: Reflections on the Screen (New York: Atria Books, 2002), 144. Nick Clooney, a film critic and historian, contends that the studio’s claim is plausible. Movies were a powerful force in 1948, as the average US citizen attended the cinema 23 times a year. The big screen had a more pervasive influence than now, and reforms did occur in the period 1949-1951. 23 could befall me.”75 His first-hand experience did not dissuade him from that core assumption that asylums were the only hope thousands of mentally ill persons had to be restored to society.76 He emphasized that in most instances, “An insane person is more likely to recover in a reputable institution than if he kept in touch with the world he knew while sane.”77 He stated over and over that mental disorders could not be treated at home, and that patients were far better off in institutions.78 In fact he felt it was his “duty” to reiterate his belief that “most insane persons are better off in an institution than out of one.”79

As Cunningham left the asylum in the original Snake Pit novel, she contemplated how the mental hospital was indeed a shelter, even if it was a “shelter patients devoted their sane moments to hating.”80 The movie took this idea of a “shelter” even further, as in the end it was the asylum’s psychiatrist who guided Cunningham out of her mental illness.81 In the 1948 movie, psychoanalyst Dr. Kik navigated Cunningham’s unconscious until he triumphantly unpacked her

Oedipal complex, allowing Cunningham to achieve self-understanding and go home.82 The filmmakers’ intention was undoubtedly to condemn the overcrowding and poor conditions of asylums. Nonetheless, by portraying the hospital’s psychiatrist as the hero and vital to

Cunningham’s recovery,83 they implied an underlying faith in the asylum system as a whole.

75 Beers, A Mind that Found Itself, 61 76 id 5 77 id 61 78 id 104 79 id 255 80 Ward, Snake Pit, 275 81 Leslie Fishbein, "The Snake Pit (1948): The Sexist Nature of Sanity," American Quarterly 31, no. 5 (1979): 643, doi:10.2307/2712430, http://www.jstor.org/stable/2712430?seq=3#page_scan_tab_contents 82 id 652-654 83 This was a marked departure from Ward’s novel, where Cunningham disagreed with Dr. Kik’s diagnosis. In the novel, Cunningham experienced such “shock” by being thrown into a ward with lower- functioning patients that she resolved to get better on her own. Psychoanalysis played very little part in the original Cunningham’s recovery. 24

Around the same time as The Snake Pit, Wright assured readers that there were “always” redeeming factors in every hospital, and that these redeeming features, “even in the worst mental hospital, often made it a much healthier place for the mentally ill than can be found elsewhere.”84

Lastly there is Deutsch, who compared mental hospitals to Dante’s Inferno,85 Nazi concentration camps, and a “hell for the sick.”86 He claimed the suffering of the mentally ill was “etched deep in [his] own heart and mind,”87 and he would never forget the horrors he saw. Yet despite acknowledging that there was not a single hospital in the entire country that met minimum standards, he still dedicated the entire last chapter to pursuing “the ideal state mental hospital.”88

He applauded the “large proportion” of attendants who were “extraordinarily loyal and humane people working under great odds,”89 and admired hospitals like Brooklyn State Hospital that avoided restraints and seclusion rooms.90 Deutsch admitted that the ideal hospital was a dream, and an unrealized one at that. But he emphatically denied that it was unattainable.91

Exposés varied widely from the mid-19th century to the mid-20th century, but all shared the same fundamental goal: to reform the state hospital. It never occurred to these authors to explore other means of helping the mentally ill, or to consider solutions outside the asylum. The dual beliefs that asylums could and should be reformed were so strong that abuse was consistently overlooked and rationalized. Until the 1960s, authors and the public justified the asylum model, even when confronted with the ghastliest conditions imaginable.

84 Wright, Out of Sight, Out of Mind, 130 85 Deutsch, The Shame of the States, 49 86 id 51 87 id 13 88 id 182-183 89 id 43 90 id 152 91 id 187 25

The Rise of Anti-Psychiatry Literature

By the end of the 1960s, however, the publication of several texts radically disrupted existing mental health rhetoric. In 1961, sociologist Erving Goffman published Asylums based on his experience working in St. Elizabeth’s Hospital, a federal institution in Washington, D.C.

Over the course of four essays, Goffman proposed that the problems seen in mental hospitals were structural and inescapable. Dehumanization and de-individualization92 were intrinsic to the asylum model itself, and even chronic dirtiness was unavoidable.93

Most importantly, Goffman argued that asylums perpetuated violence and abuse. He explained that by their very nature, mental hospitals deprived patients of choice and autonomy.

When every aspect of the “self” was taken away and patients found they had no control over their lives, many sought to assert their identity by breaking rules.94 This desire to regain some semblance of control, combined with chaotic and disgusting wards, fostered a tense atmosphere that led many patients to lose composure. Yet when these forces converged on a patient and he or she understandably reacted violently, staff and attendants were forced to use violence in turn to regain control. In other situations, Goffman acknowledged that patients were legitimately capable of harming themselves or others if left unsupervised.95 For these reasons, he believed staff would always have to resort to violence and coercion to keep patients in line. But punishment did not combat the underlying factors causing patient unrest, it only reinforced a lack of autonomy. With the original cause unaddressed and even intensified, the patient would act out again and again. Bad behavior further reinforced the notion that the patient belonged in the

92 Erving Goffman, Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (New York: Anchor Books, 1961), 6-19, 74. 93 id 26 94 id 55 95 “id 77-83 26 hospital, and required staff to use more and more force to maintain control. The end result, according to Goffman, was a vicious cycle of patients reacting to the poor environment, staff misinterpreting these reactions as symptoms, and staff using violence to maintain control.

Breaking from reformers of the past, Goffman claimed that increased budgets would not fix these core problems. Even if institutions were flooded with money and resources, he believed psychological damage from dehumanization and de-individualization would still occur. Patients would still be stripped of autonomy, and attendants would still be forced to resort to violence, no matter how well they were paid. Goffman denounced asylums as a fundamentally unworkable concept, and his thought-provoking work quickly circulated the medical community.

That same year, psychiatrist Thomas Szasz offered an even more radical view than

Goffman in The Myth of Mental Illness.96 Szasz postulated that there were no true illnesses of the mind, and madness was just a false label affixed by psychiatrists to individuals that society desired to control. Philosopher Michel Foucault echoed many of Szasz’s theories in his book

Madness and Civilization, published in French in 1961 and translated to English in 1964. Then, in 1966, sociologist Thomas Scheff applied labeling theory to the mentally ill. In his essay, Being

Mentally Ill, Scheff argued that mental illness was solely the result of societal influence.

Individuals were labeled “mentally ill” because they defied societal norms, not because of any true “illness.”97 Scheff saw madness as a self-fulfilling prophecy, where those labeled “mentally ill” unconsciously changed their behavior to match the role they have been given by society.

Even novels began to balk at society’s traditional faith in mental hospitals. In contrast to

The Snake Pit and most non-fiction exposés, the asylum in Ken Kesey’s 1962 novel, One Flew

96 Thomas Szasz, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (New York: Dell Publishing, 1961). 97 Thomas Scheff, Being Mentally Ill: A Sociological Theory (Chicago: Aldine Publishing, 1966). 27

Over the Cuckoo’s Nest, was immaculate.98 Overcrowding was not a problem, the food was good, the wards clean, and patients allowed outside. Kesey’s horror did not derive from squalor, neglect, or violence. Instead, the villainous Nurse Ratched inspired fear through her complete and utter control over the patients’ lives. She humiliated and dehumanized patients, using psychological oppression to force them into submission and ensure total obedience. Kesey’s book did not condemn the tangible aspects of the asylum, or even the physical abuse perpetrated by the three attendants. His terror stemmed from the intangible, psychological trauma patients experienced. One Flew Over the Cuckoo’s Nest penetrated mainstream culture as scientific texts such as Goffman’s permeated the academic world. These works assaulted the very profession of psychiatry, and for the first time questioned the asylum’s role in society. Authors of the past believed the problems found in asylums were rooted in the implementation of the model. The new authors of the 1960s asserted that the model itself was flawed.

These revolutionary works seemed to appear out of nowhere in a span of five years.

However, that suddenness is a false impression generated by the repetitive conclusions of exposés from the 1880s to the 1950s. Subtle suspicions of the asylum model actually dwell in the background and subtext of pre-1960s exposés, but were overshadowed by the authors’ insistence that asylums could and should be reformed. Goffman, Szasz, Scheff, Foucault, and Kesey did not spring fully formed onto the scene of mental health. Rather, they were the natural culmination of an evolution in thought that originated in the concerns of patients themselves, and worked its way outwards to the public.

Initial criticism of asylums appearing in patients is logical considering patients’ intimate relationship with the asylum. Hospitals were geographically isolated and patients strictly

98 Ken Kesey, One Flew Over the Cuckoo’s Nest (New York: Signet, 1962). 28 segregated from the public, allowing no opportunity for outside citizens to experience true asylum life. Patients had a point of view hidden from the vast majority of Americans. To a certain extent, patients had more insight into asylum life than the medical community, although both occupied the same physical space. Only patients experienced the asylum 24 hours a day, seven days a week, with no ability to leave. Through their unique exposure to the inner workings of asylums, patients were the first to pick up on flaws inherent to the system.

For example, after spending less than a fortnight committed inside Blackwell’s Island,

Nellie Bly theorized that the asylum itself drove many patients insane.99 She challenged any doctor to take a sane woman and

“Shut her up and make her sit from 6 A.M. until 8 P.M. on straight-back benches, do not allow her to talk or move during these hours, give her no reading and let her know nothing of the world or its doings, give her bad food and harsh treatment, and see how long it will take to make her insane. Two months would make her a mental and physical wreck.” 100

Bly’s passage sounds almost prophetic of Goffman, who would present virtually the same argument half a century later.

Clifford Beers (a patient in three separate hospitals) also hinted at an understanding of how asylums promoted brutality. Once he overheard one attendant telling another, “When I came here, if anyone had told me that I would be guilty of striking a patient, I would have called him crazy himself. But now I take delight in punching hell out of them.”101 Beers hypothesized that the use of restraints (such as seclusion rooms and straightjackets), the asylum’s isolation, and the inability of patients to fight back all encouraged the attendants’ “baser natures.”102 Such musings

99 Bly, Ten Days in a Mad-House, Chapter 12 100 Although not technically a patient, Bly lived in Blackwell’s Asylum living and being treated as a patient. 101 Beers, A Mind that Found Itself, 228 102 id 29 are also reminiscent of Goffman, but Beers did not pursue them very far. For the most part, Beers blamed abuse on the use of restraints, not the asylum system in general. He concluded that violence could be eliminated by adopting a non-restraint policy and enforcing attendant accountability.103

Beers also explored early versions of Scheff and labeling theory. In one chapter he wrote,

“He who is potentially a madman may keep a saving grip on his own reason if he be fortunate enough to receive that kindly and intelligent treatment to which one on the brink of chaos is of right entitled.”104 Beers attributed his own recovery to being treated as a gentleman, and claimed that had doctors for “one moment” treated him as a criminal or dumb animal, he would have

“Resented their action as vigorously as I had the action of their predecessors upon prior occasions. Instead of regaining my normal poise and securing a complete freedom within a month, in all probability I should have gone from bad to worse, lashing myself into a justifiable fury that undoubtedly would have necessitated my being confined for perhaps an indefinite period.”

Beers concluded that in his experience, “madmen are too often man-made.”105

Patients like Bly and Beers were the first to express misgivings on the inner workings of asylums. Then, during the 1940s, doubts radiated outward from patients to attendants. This can be attributed to two factors. First, the neglect asylums suffered during the Great Depression and the Second World War exacerbated poor conditions to the point where they were obvious enough for attendants (and in turn the authors who interviewed them) to notice. Second, many attendants during this period were conscientious objectors. Because of their strong opposition to violence, the COs were predisposed to notice its appearance in asylum life. They picked up on the abuses and problems seen by Progressive Era patients, but disregarded by Progressive Era attendants.

103 id 233 104 id 279 105 id 30

This expanded circle of authors in the 1940s could not ignore the fact that asylums had experienced the same problems for almost a century, and that no previous reformer had successfully alleviated them. Maisel was fully aware of the countless newspaper exposés that prompted outrage, only to have the matter “die.”106 He recognized that despite the country’s best efforts, hospitals have “never” had enough personnel or funds.107 Wright knew that asylums were a “social disgrace” long before World War II, and criticized those who would solely blame the war for current conditions.108 Deutsch made the most damning case, stating that there had not been a single state mental hospital in the entire country that had ever met all the minimum standards of care and treatment.109 He was familiar with Dix, Beers,110 and Bly,111 and knew the futility of their efforts. He wrote, “There have been countless newspaper exposés of mental hospitals since Nellie Bly in 1887 wrote “Ten Days in a Madhouse” … What good have such exposés accomplished? Very little, if anything.”112 Wright, Maisel, and especially Deutsch knew from their predecessors that simply exposing poor conditions was not enough to fix asylums.

Mounting failures pushed authors to examine why their historical counterparts were unsuccessful. The result was a deeper analysis of the problems asylums faced, and with it came growing recognition of flaws in the system. For example, Maisel, like Beers, explored attendant abuse. But where Beers was confident the removal of restraints would eliminate physical abuse,

Maisel knew this is not the case. Coming 20 years after Beers, he was aware that even without restraints there was still widespread physical abuse in asylums. Maisel could not solely attribute

106 Maisel, Bedlam 1946, 116 107 id 103 108 Wright, Out of Sight, Out of Mind, 131 109 Deutsch, The Shame of the States, 183 110 id 13 111 id 64 112 id 177 31 abuse to restraints, and had to rationalize its continuation. He titled an entire section

“Overcrowding Breeds Abuse,” and shifted the blame to long hours, low pay, and chaos from overcrowding. He observed how it was the chaotic asylum environment that contributed to mistreatment and abuse, driving orderlies and attendants to rely on violence to keep peace.

Maisel distinguished that attendants were not inherently cruel people, but individuals operating in an extremely demanding environment and responding rationally to a stressful situation.

Wright developed similar ideas. As stated previously, the CO’s he interviewed for his book were excluded from the draft because of their adherence to non-violence. Yet even they struggled to remain composed while working in mental hospitals. The COs described wards where they were “assaulted by the vocal discord of two hundred disordered minds,”113 and where they were physically threatened by violent patients.114 Some recounted how they eventually resorted to violence to control their unruly wards. One CO reported, “Although we were told repeatedly that our handling of patients was much better than that of the former attendants, the frustrations encountered gave rise to fits of temper which at times resulted in unnecessarily rough language and rough handling of patients. This loss of control grew more frequent as the time on the ward grew longer.”115 Another remembered a patient telling him, “I thought I was coming here to get a rest and quiet my nerves. Why, this place would drive a guy nuts!” The attendant admitted that he knew this was true, for there were times when it almost drove him “nuts.”116

Wright’s book was based on hundreds of men who saw first-hand how the very nature of an asylum drove attendants to abuse, and he touched on this theme frequently throughout the book.

113 Wright, Out of Sight, Out of Mind, 20 114 id 41 115 Steven Taylor, Acts of Conscience: World War II, Mental Institutions, and Religious Objectors (Syracuse: Syracuse University Press, 2009), 220 116 Wright, Out of Sight, Out of Mind, 20 32

Deutsch also stressed that physical violence and attendant abuse was a problem. However to him, even more “serious defects” arose from the “deadly monotony of asylum life, the regimentation, the depersonalization and dehumanization of the patient, the herding of people with all kinds and degrees of mental sickness on the same wards, the lack of simple decencies, the complete lack of privacy in overcrowded institutions, the contempt for human dignity.”117

Deutsch’s passage sounds like it could have been lifted out of Goffman’s Asylums, despite the fact that it was written a decade earlier. Deutsch goes on to write that while Dix and Beers were commendable, they were unsuccessful and the day of the “individual crusader was over.” Only a

“fundamental reform” of the hospital system could correct the wrongs he witnessed.118

Maisel, Wright, and Deutsch’s analyses of the past cultivated greater doubts of the asylum model than seen in either Beers or Bly. However, they stopped short of fully exploring the root cause of the problems they saw. They still instinctively fell back on the belief that underfunding was to blame for all issues, even systemic ones. Wright glossed over any nuance he explored in earlier chapters when he summed up “all the reasons why care for mental patients is so inadequate” in one word: “poverty.”119 Despite his understanding of how attendants were affected by their environment, Maisel’s main problem with asylums remained an overall

“skimping” of the budget.120 He concentrated on the “penny-pinching” surrounding food, wages, and building maintenance. 121 Even his discussion on incompetent doctors and overcrowding stemmed from underfunding. He ultimately affirmed the possibility of reform, pointing to states such as Delaware who managed to secure an “adequate number of doctors, nurses, and

117 Deutsch, The Shame of the States, 28 118 id 13 119 Wright, Out of Sight, Out of Mind, 145 120 Maisel, Bedlam 1946, 109 121 id 110 33 attendants…. Even within individual states some outstanding superintendents have managed to raise their institutions to a decent level despite low pay scales and heavy overloads.”122

Deutsch, the most progressive of the three, explained in one chapter that mental health was “traditionally handled in the easiest and stupidest way- by pouring millions into brick and mortar to build bigger and bigger institutions.”123 This observation is comparable to the rhetoric of the 1960s, and Deutsch appeared as though he was going to recommend shifting focus away from the mental hospital. But, instead of suggesting a departure from the asylum model, Deutsch simply recommended spending the money in a different way. He clarified,

“Chronic overcrowding, understaffing and lack of adequate therapeutic equipment have often rendered active treatment next to impossible … Too often liberal legislative appropriations to state hospital systems have been buried in brick and mortar- in the erection of bigger but not better institutions- instead of being poured into active therapy and research.”124

He affirmed that more money would bring in higher-quality attendants, which would lead to more people being “cured,” which would alleviate overcrowding. Deutsch may have prided himself on being part of a “new crusade,”125 but he simply held an evolved version of the “money will fix asylums” stance.

This new generation of reformers did not write their exposés in a vacuum. They had to take into account the failed reforms and reformers of the past. As a result, they could not dismiss dozens of deteriorating hospitals as isolated incidents, caused solely by one city or state failing to provide adequate funds. Deutsch illustrated the growing perception that something was deeply wrong when he wrote, “I knew that to find the real causes of the conditions I witnessed, I would have to seek beyond the scapegoat, beyond the lurid incident, back to the deep-seated sources of

122 id 103 123 Deutsch, The Shame of the States, 136 124 id 38 125 id 172 34 chronic evils and abuses, back to the real culprit- the state hospital system.” 126 This recognition that the entire asylum system was problematic was a significant progression in thought, and tied directly to the growth of anti-psychiatry literature. In fact, modern readers familiar with 1960s anti-asylum literature can see traces of Goffman, Foucault, Scheff, and Szasz throughout the

1940s exposés. But even after acknowledging the need for “fundamental reform,” the 1940s authors’ basic recommendation was still to pour more money into asylums. By making the root cause of the failed asylum system underfunding, these authors demonstrated undiminished faith that the asylum model could work. They did not attack its theoretical tenets, nor discredit its role in society. If anything, these authors compensated for their uncertainty by making the boldest proclamations yet. Deutsch rhetorically asked, “Are such conditions an inevitable part of a state care system? I certainly do not think so. In my considered opinion, there is nothing inherently bad in any system of government-sponsored medicine, including state hospital psychiatry.”127 In the same vein, Maisel pondered, “As evidence mounts up one is led, inevitably, to the question,

‘Can things like this ever be corrected?’ Fortunately, the answer is ‘Yes,’ or rather, ‘Yes but it takes hard work.’”128 Wright also adamantly maintained in his epilogue that high-quality hospitals were both “possible and desirable.”129 Maisel, Wright, and Deutsch more forcefully defended the asylum system than either Beers, Bly, or Dix, demonstrating how faith in the asylum model remained firm. However, doubt and tension were apparent, and the authors of the

1940s shifted closer to anti-psychiatry literature with the acknowledgement that the entire asylum system could be broken.

Uncertainty continued to build as time passed and it became clear the reforms of the

126 id 135 127 id 142 128 Maisel, Bedlam 1946, 116 129 Wright, Out of Sight, Out of Mind, 124 35

1940s were not working. By the 1960s, the American people were in an ideal place to reevaluate the place of the mentally ill in society. The discovery of concentration camps and the “Final

Solution” during World War II provided an important stimulus to reevaluating mental hospitals.

The mentally ill were driven to Nazi furnaces in vast numbers along with Jewish communities.130

Americans were horrified when they discovered the ties the genocidal Final Solution had to

American eugenics. Not only had German eugenicists formed academic and personal relationships with American eugenicists, but multiple American charities had supported German eugenics research. The Carnegie Institute, Rockefeller Foundation, and countless other well- respected organizations all funded the early beginnings of the Nazi eugenics movement.131

American eugenics laws inspired Hitler himself as he was serving time in prison for mob action.

He pored over American eugenics textbooks, going so far as to call Madison Grant’s Passing of the Great Race his “bible.” Hitler cited American eugenics language in his autobiography Mein

Kampf, used American eugenics legislation as the blueprint for his eugenicist state, and pointed to American studies as scientific verification of his policies.132 Nazi scientists even cited

American laws in their defense when their actions were charged as crimes against humanity,133 as well as United States Supreme Court cases defending eugenics.134

Americans condemned Nazis, and concentration camps were the epitome of their evil.

Castigating Nazis became a method to bolster American moral superiority. However, immediately after the war, the exposés of the 1940s forced Americans to confront the

130 Scull, Madness and Civilization, 335 131 Stefan Kuhl, The Nazi Connection: Eugenics, American Racism, and National Socialism (New York: Oxford University Press, 1994), 20. 132 Edwin Black, “Hitler’s Debt to America,” The Guardian, February 5, 2004, https://www.theguardian.com/uk/2004/feb/06/race.usa. 133 id 134 Edwin Black, “Eugenics and the Nazis- The California Connection,” San Francisco Gate, November 9, 2003, http://www.sfgate.com/opinion/article/Eugenics-and-the-Nazis-the-California-2549771.php 36 concentration camps in their own backyards. As early as 1946, exposé authors were denouncing asylums as concentration camps and drawing persuasive parallels between the two. Deutsch opened a chapter of The Shame of the States with an anecdote about Dr. Karl Brandt, personal physician to Adolf Hitler and director of the mass-scale slaughter of mentally and physically handicapped Germans. While on trial as a war criminal, Brandt presented his philosophy that

“The life of an insane person is not in keeping with human dignity.” He called the mentally ill and developmentally disabled “useless eaters,” and declared it a mercy to shorten their lives.

Brandt maintained that the cost to maintain an asylum was a “great price for the state to pay,” and the money would be better built on battleships.135 Deutsch wrote that “the spines of many

American readers were chilled when the Nuremberg dispatches renounced the details of the Nazi euthanasia program … The thought flashed through many a mind: ‘Thank Heaven, we are not like that.’”136 He then forced readers to abandon that feeling of superiority, claiming, “No, indeed, we are not like the Nazis. We do not kill off ‘insane’ people coldly as a matter of official state policy. We do not kill them deliberately. We do it by neglect.’”137 Nazi Germany held up a harsh mirror to American policy regarding the mentally ill, forcing Americans to face the logical conclusion of their own position towards these individuals. Nazi revelations effectively ended the American eugenics movement that until then had enjoyed great popularity, although it would resurface in a more racialized and less genetic manner in the 1950s.

Asylums had long avoided scrutiny, as they were considered the natural response to the mentally ill. But after World War II, concentration camps forced Americans to reevaluate the morality of segregating and isolating an entire group of people. Parallels between Nazi Germany

135 Deutsch, The Shame of the States, 96 136 id 137 id 37 concentration camps and American asylums posed a massive problem for the image of American superiority, and this new perspective on mental hospitals added to the tension caused by another round of failed reform efforts. By the late 1950s, doubts percolated up through the ranks until even superintendents and psychiatrists were calling the feasibility of asylums into question. In

1958, Dr. Harry Solomon, Superintendent of the Massachusetts Mental Health Center, condemned the asylum system in his speech as President of the American Psychiatric

Association. He called the large mental hospital system,

“Antiquated, outmoded, and rapidly becoming obsolete …. After 114 years of effort, in this year 1958 no state hospital has an adequate staff … I do not see how any reasonably objective view of our mental hospitals today can fail to conclude that they are bankrupt beyond remedy. I therefore believe that our large mental hospitals should be liquidated as rapidly as can be done in an orderly and progressive fashion.”138

In direct response to a century of failed reforms, Solomon, a major psychiatric figure, now called for the replacement of mental hospitals with smaller, community based centers.

Suspicion of the asylum model had also spread outwards, beyond the psychiatric community. In 1956, sociologist Ivan Belknap wrote Human Problems of a State Hospital, a harsh exposé of an anonymous “South State Hospital.” In the foreword, Dr. Alfred Bay of the

Topeka State Hospital explained that countless reformers (including Philippe Pinel, Dorothea

Dix, Clifford Beers, and several of Bay’s contemporaries) were unable to break the cycle of

“exposé, reform, progress, indifference, apathy and decline.” This cycle, Bay argued, “Has repeated itself too often to be fortuitous … the uneasy feeling exists that reform and regression in mental hospital affairs are inseparable processes.”139 Belknap expanded upon this foreword, and explained how isolation, centralization, large size, and welfare responsibilities had become

138 Joint Commission on Mental Illness and Health, Action for Mental Health, 267-268 139 id vii 38 inextricably tied to the asylum model.140 He concluded that these were unresolvable issues, and rather than helping the mentally ill, “hospitals have become organized in such a way … that they are probably themselves obstacles in the development of an effective program for treatment of the mentally ill.”141 Belknap did not call for increased funds, or a reform of the hospital system.

Instead, he claimed, “In the long run the abandonment of the state hospitals might be one of the greatest humanitarian reforms …. ever achieved by South State.” Similar to Solomon, Belknap proposed that the “ideal mental health organization should be kept in the local communities.”142

In 1958, Solomon and Belknap’s opinion was still the minority. Most members of the psychiatric community continued to ardently support the hospital system. Dr. Mesrop

Tarumianz, chief psychiatrist for the State of Delaware, cautioned against early abandonment of public mental hospitals. He defended, “There are many small hospitals for the mentally ill, private as well as public, that do not have as good facilities and services as some of the larger institutions have.”143 Belknap himself admitted in his conclusion that the abandonment of the current system in favor of community care was “of course too much to hope for with the present tremendous investment of capital, interests, and habits in the state hospitals of South State.”144

The backlash against Solomon and Belknap’s critiques demonstrated how the psychiatric community was still supportive of asylums. However, the repeated failure of reform wave after reform wave could not be completely ignored.

In 1961, a Joint Mental Health Commission released a massive, years-long study on

Mental Health in the United States. The report was compiled by scientists in the mental health

140 Ivan Belknap, Human Problems of a State Mental Hospital, 212 141 id xi 142 id 212 143 Lawrence Davies, “Mental Hospital Called Outmoded,” New York Times, May 13, 1958, http://journals.sagepub.com/doi/pdf/10.1177/107755875801500707 144 Belknap, Human Problems of a State Mental Hospital, 212 39 field, and showed a fascinating sense of self-awareness. The authors also demonstrated a comprehensive understanding of the uselessness of exposés, mentioning Dix, Beers, Deutsch, and several others.145 With a sense of superiority, the report recounted,

“Attempts to provide more humane care for the mentally ill and to transform mental institutions into hospitals and clinics true to the healing purpose of medicine have occurred periodically during the last two centuries. While each reform appears to have gained sufficient ground to give its supporters some sense of progress, each has been quickly followed by backsliding, loss of professional momentum, and public indifference. The Joint Commission and the Mental Health Study came into being as an expression of the new wave of interest, movement, and progress in mental health that followed World War II. The Commission’s leaders held the opportunity presented by Congress to take stock and evaluate new directions to be ‘a chance of a lifetime.”146

In 1961, the weight of failed reforms appeared even heavier than when Maisel, Wright, and

Deutsch wrote their exposés. Reflection on the cyclical failures of the past pushed mental health experts to finally consider other possibilities besides public mental hospitals. The 1961 report showed the first widespread support for a system other than the public asylum, and moved away from the mindset that asylums were the default response to the mentally ill. Instead, it recommended that community mental health clinics should be the “main line of defense in reducing the need of many persons with major mental illness for prolonged or repeated hospitalization.”147 Community care was not an afterthought, but the very first recommendation the committee made.148

When the commission did approach the concept of mental hospitals later in the report, it did so with ambivalence. The authors cited Dr. Solomon as an influence on their report, and agreed with his assessment of large hospitals. The report explicitly recommended that no further hospitals of more than 1,000 beds should be built, and not a single additional patient should be

145 Joint Commission on Mental Illness and Health, Action for Mental Health, 12 146 id xxix-xxx 147 id 262-263 148 id XIV 40 added to existing state hospitals of more than 1,000 beds. There is a distinct pivot away from large mental hospitals and towards community care. However, the commission did not yet take the step of condemning asylums altogether. The report did not call for the elimination of mental hospitals under 1,000 beds, and pointed out that “many of the large state hospitals do a reasonably good job of treating chronically ill persons, but lack the manpower to give the acutely ill the intensive, individualized attention needed.”149 The report also noted,

“It is concerning that so many psychiatrists are trained at public expense and then go into private practice. Greater efforts must be made to persuade these men that they have a moral obligation to pay back time equivalent to the period of their training by taking positions in either part-time or full-time public service … this calls for studied efforts to make public mental hospitals and clinics professionally desirable places to work.”

The “dire” need for psychiatrists who were “particularly interested in hospital and clinic psychiatry” indicated the report did not foresee hospitals disappearing anytime soon.150

Additionally, toward the end of the report, the commission pointed to Veteran’s

Administration mental hospitals as “financial models of what can be done in the operation of public mental health hospitals.” According to the report, V.A. mental hospitals had on average three times the federal funding as similarly sized state mental hospitals. This more “fortunate” financial position allowed V.A. hospitals to explore more efficient treatment, and develop hospital management “not so freighted with custodial restrictions.” The report recommended that local governments “emulate the example set by V.A. mental hospitals.”151 Such language revealed that on some level, the commission stubbornly retained the traditional belief that underfunding was to blame for asylums’ ills. Despite the progressive passages in the report, the medical community was clearly not ready to entirely abandon the asylum model. However, the

149 id 267-268 150 id 250-251 151 id 287 41 very consideration of options other than the asylum indicated a development in thought regarding mental illness.

By the time Goffman published his book in 1961, faith in the asylum system had been severely shaken. Since the 1890s, criticism spread like a gyre outward from patients to attendants, then to superintendents, then to scientists outside the psychiatry profession. Goffman,

Szasz, Foucault, and Scheff simply took the next step of this evolution. They were able to skillfully articulate what other exposés had hinted at, but been unable to pinpoint. Issues that had previously been overshadowed by optimistic conclusions now took center stage.

The very acknowledgement that the system could be flawed was profoundly important.

As Thomas Szasz explained in his 1977 book, Psychiatric Slavery,152

“The most powerful justification for an act, and especially a socially established practice, is no justification at all. The most completely justified forms of conduct are those for which no justification is offered because none is expected. A dramatic example of this is the absence of any reference to slavery in the Constitution … another is the absence, until recently, of any reference in psychiatric texts to the fact that so-called psychiatric patients are, in fact, patients against their will. Not mentioning the involuntary servitude of Negroes or the involuntary patient-hood of madmen is thus the most powerful justification possible of their enslavement and imprisonment ... Once the systematic oppression of one group by another becomes fully articulated and is maintained by offering some sort of justification for it, its days are numbered.”153

Until the 1960s, asylums had been tacitly accepted as “obviously right.” Goffman, Szasz,

Foucault, and Scheff broke this justification by silence. Their works were by no means universally accepted. But by putting forward their arguments in the first place, these authors stimulated fresh debates and discussions on mental health. Supporters of the asylum now had to defend the model’s efficacy and morality. The accuracy of Goffman, Szasz, Foucault, and

Scheff’s texts was not as important as the fact that the authors forced American society to

152 Szasz actually wrote Psychiatric Slavery to dissect the O’Connor v Donaldson case, which is discussed at length in Chapter 5. 153 Thomas Szasz, Psychiatric Slavery (New York: The Free Press, 1977), 5 42 reevaluate a previously unchallenged institution.

Once the fundamental feasibility of asylums was questioned, other options were explored in earnest for the first time. President Kennedy, deeply affected by the 1961 Congressional report, embraced the theory that asylums were structurally flawed.154 In a special message to

Congress on February 5, 1963, he implored legislators to alleviate the twin problems of mental illness and mental retardation, what he called the “most critical” of health problems. Echoing muckrakers of the past, he reiterated that most of the mentally ill were “confined and compressed within an antiquated, vastly overcrowded, chain of custodial state institutions.” He suggested a

“bold new approach” centered around community care. Through this approach, “Reliance on the cold mercy of custodial isolation will be supplanted by the open warmth of community concern and capability.” Social quarantine in “unhappy mental hospitals” was obsolete, and “all but a small portion of the mentally ill” could live in the community. President Kennedy radically departed from suggestions of the past, claiming, “Central to a new mental health program is comprehensive community care. Merely pouring Federal funds into a continuation of the

154 John F. Kennedy, “Remarks on Signing Mental Retardation Facilities and Community Health Centers Construction Bill,” John F. Kennedy Presidential Library and Museum, October 31 1963, https://www.jfklibrary.org/Asset-Viewer/Archives/JFKPOF-047-045.aspx. President Kennedy is another figure demonstrating how doubts in the asylum system originated in individuals close to it. Kennedy’s younger sister Rosemary had behavioral issues and intellectual disabilities, and was lobotomized 20 years before Kennedy was elected president. The lobotomy failed, and left Rosemary permanently incapacitated. She was incontinent and could not walk or speak. Rosemary spent the rest of her life in an institution, although her family kept her condition a secret until well after her brother was elected president. To Kennedy, mental health was not “someone else’s” problem. It was a very real and recurring issue for his very family, albeit one they kept under wraps. Largely because of Rosemary, President Kennedy was primarily concerned with developmental disabilities throughout his presidency. He paid virtually no attention to the mentally ill or their conditions, focusing instead on improving the status of the mentally handicapped. Indeed, the full title of the 1963 Community Mental Health Act was actually the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963. In Kennedy’s remarks on the bill, he speaks at length how the bill will benefit the developmentally disabled. Mental illness is only directly mentioned twice throughout the lengthy speech. Nonetheless, because mental illness was associated with developmental disabilities, mental illness was given more attention during Kennedy’s presidency than it would have been had the president had no ties to mental health. 43 outmoded type of institutional care which now prevails would make little difference. We need a new type of health facility.” Kennedy was confident that hospitals were no longer meant to be the primary response to the mentally ill, and that community care was a more humane option.155

The legislation that eventually resulted from Kennedy’s efforts, the 1963 Community Mental

Health Act,156 was equally focused on community care over state hospital care.

At first glance, society seemed poised to pivot away from the asylum system. However, condemnation of mental hospitals was not accompanied by a corresponding decline in hospital populations. Seven years after the passage of the 1963 Community Mental Health Act, asylum populations had hardly changed.157 More importantly, admission numbers were still rising.158

Passionate and public calls to replace asylums with community care went largely unfulfilled. As late as 1975, state mental hospitals accounted for more than 2/3rds of all inpatient care.159

One cannot understate the importance of the anti-psychiatry texts that emerged in the

1960s. From the 1890s to the 1950s, a deep-rooted belief in the asylum system overpowered any misgivings or doubts reformers had about the problems they saw. Only through revolutionary literature questioning the asylum’s basic principles and functions were other options even explored. However, undermining that faith through scholarly criticism was not enough to empty asylums. The system was open to collapse, but it took the involvement of another movement to produce large-scale deinstitutionalization.

155 John F. Kennedy, “Special Message on Mental Illness and Mental Retardation,” John F. Kennedy Presidential Library and Museum, February 5, 1963, https://www.jfklibrary.org/Asset- Viewer/Archives/JFKPOF-052-012.aspx 156 Signed on October 31, 1963, the Community Mental Health Act was the last piece of legislation JFK signed before he was assassinated a few weeks later. 157 Grob, The Mad Among Us, 291 158 id 267 From 1955 to 1970 admissions rose from 178,003 to 384,511. 159 id 44

Chapter 4: External Pressure from the Civil Rights Movement Changing the Strategy of Reform

The writings of the 1960s were critical to overcoming a seemingly unshakeable faith in asylums. However, vulnerability in the system would not have catalyzed any change without influence from the Civil Rights Movement. The Civil Rights Movement not only ushered in a general atmosphere of social upheaval, but trail-blazed the use of the judiciary as a means for minorities to assert their rights.

According to historian David Rothman, the Civil Rights Movement fundamentally changed how reform occurred. Prior to the 1950s, the fight for minority rights was typically conducted by professionals advocating on a minority’s behalf. Progressive and New Deal reformers were wary of a judiciary that consistently struck down their work in favor of private corporations, and instead chose to work through the legislature. Activists would petition

Congress and legislators on behalf of minorities, in what were essentially lobbyist efforts.160 The ensuing legislation was often paternalistic, such as bills regulating workers’ hours and wages or prohibiting women from working in strenuous occupations.

The Civil Rights Movement broke from this long-standing strategy. It recognized that while a few notable reform efforts were effective, the overall strategy failed frequently. As a politically impotent minority, African-Americans did not constitute a majority of voters or wield significant power. As such, their needs were largely ignored by the popularly elected legislative and executive branch.161 African-Americans knew that by the very definition of democracy, their rights were vulnerable to curtailment by the majority, and had been infringed on frequently.

160 David Rothman, Sheila Rothman, The Willowbrook Wars (New York: Harper & Row, 1984), 51. 161 Eugene Rostow, “The Democratic Character of Judicial Review,” Harvard Law Review 66, no. 2 (1952): 203, http://digitalcommons.law.yale.edu/cgi/viewcontent.cgi?article=3158&context=fss_papers. 45

Rothman continued, “No black determined to desegregate Southern schools could conceive of the legislature as anything but the enemy. Imagine mounting an integration in the 1930s in

Jackson, Mississippi, or in the 1940s in Montgomery, Alabama.”162 Instead, they were forced to turn to a body that was not “beholden to the grace of excited majoritarianism.” That is, the

Supreme Court.163 Beginning in the 1930s, the National Association for the Advancement of

Colored People started a 25-year-long litigation effort that would eventually culminate in Brown v Board of Education in 1954.164 After the success of Brown, the Civil Rights Movement initiated dozens of other court cases ranging from desegregating public places to allowing interracial marriage. A series of landmark decisions slowly dismantled the widespread doctrine of “separate but equal,” establishing the judiciary as the most powerful ally of politically impotent minorities.

This strategy of relying on the judiciary was groundbreaking. It shifted the model from well-meaning (but nonetheless paternalistic) allies advocating on behalf of minorities to minorities identifying their own oppression and fighting for constitutional rights they were being denied.165 African-Americans established themselves as equal citizens being unconstitutionally repressed by the group in authority, challenging the existing power dynamic. Their actions spurred other groups to question their basic place in society, and to examine social conventions that had mostly gone unquestioned. For example, after comprising a vital part of the workforce in World War II, a growing number of women felt constrained by traditional gender roles.

Feminist literature such as The Feminine Mystique criticized the meek and submissive housewife

162 Rothman, The Willowbrook Wars, 51 163 Jesse H. Choper, “On the Warren Court and Judicial Review,” Catholic University Lecture Review 17 (1967), 41, http://scholarship.law.berkeley.edu/cgi/viewcontent.cgi?article=1255&context=facpubs 164 Rothman, The Willobrook Wars, 51 165 id 52 46 stereotype prevalent in the 1950s, and feminist groups like the National Organization for Women rapidly grew in numbers. During the second half of the decade, the gay rights movement gained force and manifested in violent events such as the Stonewall Riots of 1969. Prisoners began advocating for rights even as they were confined in jails. Taking cues from the Civil Rights

Movement, these groups turned to local courts, state courts, and the Supreme Court in particular to fight oppressive government and societal institutions. The courts rose wholeheartedly to this role, making a series of landmark decisions in favor of minority rights.

According to Professor Robert McCloskey, the rise of the judicial branch as a vehicle for civil rights was “a predictable response to the wave of history." Until World War II, one of the main priorities of the Supreme Court was economic regulation. Then on the eve of the conflict, the Supreme distanced itself from this role. The vacuum created by stepping away from commerce forced the Supreme Court to pivot in a new direction, and one of the most pressing national needs seemed to be social and political inequalities. Largely because of the Civil Rights

Movement, the Warren Court of 1953-1969 recognized that America was in the midst of a social revolution, and abandoned the passivity of past courts.166 It was both praised and criticized for the scope of its activism, which reached far beyond the African-American segregation cases it is most famous for.167 The Warren Court handed down the first ruling to deal with LGBTQ rights,168 upheld the freedom of religious minorities,169 provided landmark protections to

166A. Kenneth Pye, “The Warren Court and Criminal Procedure,” Michigan Law Review 67, no. 2(1968): 256, http://scholarship.law.duke.edu/cgi/viewcontent.cgi?article=5627&context=faculty_scholarship 167 Choper, “On the Warren Court and Judicial Review,” 29 168 One, Inc v Olesen, 355 U.S. 371 (1958), protected LGBTQ freedom of speech rights, upholding that a love story involving two lesbians was not automatically obscenity. 169 Engel v. Vitale, 370 U.S. 421 (1962), and Abington School District v. Schempp, 374 U.S. 203 (1963), eliminated state sponsored Christian prayer in US schools. 47 prisoners and the criminally accused,170 and protected the rights of political dissidents. 171 The

Warren Court displayed an unprecedented “concern for equality before the law,” and placed a much heavier emphasis on members of society who until then had been overlooked or ignored.172

The Civil Rights Movement began this widespread trend of reevaluating rights, fostering an atmosphere uniquely receptive to anti-asylum literature.

The Civil Rights Movement set a strong legal foundation that the mentally ill and their advocates could build on to protect patient rights. In fact, the situation of the mentally ill paralleled the situation of African-Americans in many ways. Both groups had powerful negative stigmas associated with them that devalued their lives and called into question their very humanity. Both were segregated and isolated from “normal” society, experienced intense discrimination, and were the subject of fear from mainstream society. Both were politically impotent minorities who did not have the numbers to exercise significant power in the legislative or executive branch. When African-Americans overcame this obstacle by pioneering the use of the judiciary, it set a powerful example for the mentally ill to follow.

170 Miranda v Arizona, 384 U.S. 436 (1966), protected against self-incrimination. Gideon v Wainwright, 372 U.S. 335 (1963), upheld the right to adequate council in all cases, whereas before it was limited to capital cases. Mapp v. Ohio, 367 U.S. 643 (1961), determined that evidence obtained in violation of the Fourth Amendment, which protected citizens against "unreasonable searches and seizures," may not be used in criminal prosecutions. 171 Choper, “On the Warren Court and Judicial Review,”29 172 id 41 48

Personal Connections to the Civil Rights Movement

New York lawyer Morton Birnbaum became one of the first people to demand rights for the mentally ill, especially those confined in institutions. A Jewish man who grew up in an impoverished, Yiddish-speaking family, Birnbaum’s daughter attributed his initial interest in working with the mentally ill to his compassion for the “disenfranchised.” After working odd jobs to finance law school and medical school, his first real employment was serving the medical needs of the indigent poor in Brooklyn. According to his daughter, Birnbaum “thrived on crusading for a worthy cause and challenging the status quo.” Having experienced oppression and disadvantage first hand, he empathized with the oppression of the mentally ill and sought to correct it.173

In 1960, Birnbaum published a legal paper contending that patients committed in state mental hospitals had a constitutional right to adequate treatment. This sounds like common sense, but at the time it was revolutionary. State mental hospitals had no legal obligation to provide any sort of treatment, and the vast majority were little more than warehouses. Birnbaum claimed this was a violation of the due process clause of the 14th Amendment, which stated that no citizen shall be “deprived of life, liberty, or property without the due process of the law.” His rationale was that if a person was involuntarily institutionalized in a mental hospital, that person was effectively a prisoner, albeit in a mental hospital. Predicating that prisoner’s release on recovery, then offering no chance at recovery through adequate treatment, amounted to a substantial violation of the due process clause. Such actions held a person against their will despite the fact that he committed no crime, thus illegally abridging their liberty and curtailing

173 Rebecca Birnbaum, “My Father’s Advocacy for a Right to Treatment,” The Journal of the American Academy of Psychiatry and the Law Online, March 2010, Vol. 38 Issue (1): 115-123, http://jaapl.org/content/38/1/115 49 their rights with no justification. Birnbaum concluded that state hospitals either had to immediately begin treating patients, or set them free.174

Birnbaum hoped to use his legal theory to combat what he saw as society’s systematic repression of the mentally ill. He credited the origin of this concept to a book he read by Dr.

James P. Comer, a black psychiatrist at Yale University. In a paper on racism, Dr. Comer explored the idea of the “white mind.” To Comer, it appeared that white people often seemed impervious to racist realities. Comer saw this denial of racism by whites as

a blind spot that permits otherwise intelligent people to see, thinking and act in a racist way without the expected level of guilt and pain … this failure to see, acknowledge, or understand the peculiar experience and special problems of African-Americans is racism, pure and simple … it is the unwanted product of growing up in a society where racist viewpoints are transmitted from generation to generation by people and by their institutions. To avoid anxiety and guilt, it has been necessary over the years for many racists to deny that human and constitutional rights of African-Americans have been violated. But the violation has been so flagrant that denial alone is not enough. So the white mind adds rationalization and justification. Through these psychological mechanisms, the white mind has managed to establish the notion that no consequential violation has ever taken place.175

As Birnbaum read Comer’s work, he began to realize “that our society's irrational mechanisms of oppression of blacks which Dr. Comer were describing were similar in operational procedures to the operation of our society's irrational mechanisms of oppression of the involuntarily civilly committed.”176 Birnbaum’s friend from Columbia Law School, Florynce Kennedy, encouraged him to dig deeper into this comparison. A passionate feminist and black rights activist, Kennedy was one of Birnbaum’s self-proclaimed heaviest influences. The two had frequent discussions on the “pathology of oppression” that afflicted African-Americans, women, the LGBTQ

174 Morton Birnbaum, "The Right to Treatment," American Bar Association Journal 46, no. 5 (1960), 503, http://www.jstor.org/stable/25721181 175 Birnbaum M., “The Right to Treatment: Some Comments on its Development,” 106 176 id 107 50 community, and the mentally ill. 177 Discussions with Kennedy about racism and sexism eventually led Birnbaum to coin the term “sanism” to describe societal oppression and discrimination against the mentally ill.178 In describing sanism, Birnbaum explained,

“Analogous to the claims of blacks that they are oppressed by the bigotry of our racist society, and analogous to the claims of women that they are oppressed by the bigotry of our sexist society, so can the severely mentally ill, and particularly the involuntarily civilly committed, claim that they are invidiously and irrationally oppressed by the bigoted thinking, feeling and behavior patterns of our sanist society.”179

Comer and Kennedy gave Birnbaum insight into a phenomenon he had witnessed, but until then had been unable to articulate.

The Civil Rights Movement had already popularized the idea, at least amongst liberal circles, that there were pervasive and deep-rooted stigmas in American society against certain groups. Institutionalized discrimination was not a novel concept, and Birnbaum was able to use racism as scaffolding to build upon his new idea. He showed that many of the legal setbacks he experienced could be attributed to sanism. In one case in 1960, a New York Supreme Court judge told Birnbaum, “Counselor, if you are really suggesting to me that I should let a crazy man out of a state hospital while he is still crazy merely because he is not getting proper care and treatment, then you must think that I am crazy.”180 In another case, Birnbaum arrived early to an appeal involving a mentally ill patient being confined against his will in a hospital. In all three cases preceding his (the first involving a convicted armed robber, the second a heroin dealer, and the third a recidivist pimp), attorneys sought release on procedural grounds. The judges patiently listened to each case and weighed the counsel’s arguments on its merits. In striking contrast, when Birnbaum argued that his client with paranoid schizophrenia was not dangerous to himself

177Birnbaum, R., “My Father’s Advocacy for a Right to Treatment” 178 Birnbaum M., “The Right to Treatment: Some Comments on its Development,” 107 179 id 105 180 id 51 or others, the judges interrupted him almost immediately. With sheer incredulity, they asked if he was seriously recommending that an insane man be released from the hospital. They dismissed the case without hearing any further arguments. The dismissal of a case solely on the grounds that the defendant had a mental illness typified what Birnbaum defined as sanism. To him, sanism pervaded all facets of society and obstructed justice for the mentally ill. Through Civil

Rights rhetoric, he was able to present this sophisticated theory in a current and relatable way.181

Birnbaum’s right to treatment doctrine became the deinstitutionalization equivalent of

“separate is inherently unequal.” The first case to utilize this new principle was Rouse v

Cameron182 in 1966. Charles Rouse had been involuntarily committed to St. Elizabeth’s Hospital

(the federal institution in Washington, D.C. where Erving Goffman conducted his research) when he was found not guilty by reason of insanity of carrying a loaded pistol. After three years of confinement, Rouse filed a habeas corpus action suit, alleging among other things that he was receiving no treatment at the facility. Lead council for Rouse on the case was Charles Halpern.

Halpern was a young lawyer who had just graduated from Yale and worked for the prestigious

Washington, D.C. firm Arnold & Porter. He was an avid lover of his pro bono work, and spent his first summer out of law school volunteering in Louisiana for the Lawyers Constitutional

Defense Committee, a group that provided legal assistance to the Civil Rights Movement.

Halpern lived in a small rental house in the black part of town, ate in restaurants where he and his fellow volunteers were the only white people, and regularly attended Civil Rights meetings.

In one such meeting, James Farmer, then director of the Congress of Racial Equality, spoke of a

“new world in which blacks would be able to vote and go to integrated schools.”183 Halpern

181 Birnbaum R., “My Father’s Advocacy for a Right to Treatment” 182 373 F.2d 451 (D.C. Cir. 1966) 183 Charles Halpern, “Escape from Arnold & Porter,” American Bar Association Journal Online, Feb. 1, 2008, http://www.abajournal.com/magazine/article/escape_from_arnold_porter 52 called this gathering in a rural black church a “defining moment of my life.” He later wrote,

“Despite its brevity, my time in Louisiana had fundamentally changed me, though it had no major impact on the civil rights movement. I had glimpsed another kind of law practice, where my work had meaning for me and the larger society, as well as my clients.”184

After his time in the Civil Rights Movement, Halpern was not satisfied at his corporate firm. His “real satisfaction” came from his pro bono work. He continued to pursue civil rights cases in Louisiana, and defended protesters arrested after the assassination of Martin Luther

King, Jr.185 He became known as a talented civil rights defender, and public defenders who knew that Rouse had the potential to set a national precedent recruited Halpern to take the case.

Because of his time in the Civil Rights Movement, Halpern saw the parallels between oppressed

African-Americans and oppressed mentally ill patients. He took the case, and eventually the court freed Rouse on a technicality that had nothing to do with Birnbaum’s theory. However,

Halpern discovered the same sense of meaning defending Rouse as he had found in Louisiana, and decided to shift his focus to expanding the rights of the mentally ill. Halpern demonstrates how the Civil Rights Movement influenced more than just the legal doctrine behind deinstitutionalization. It also influenced the main actors in a very personal way. After his success in the Rouse case, Halpern was recruited to participate in the next major mental health case,

Wyatt v Stickney.186

Wyatt originated in 1970 when Alabama repealed its cigarette tax. Because of the cut in revenue, the Alabama state hospital system fired 100 workers. The workers wanted their jobs back, but had no legal grounds. An attorney named George Dean suggested a backdoor approach

184id 185 id 186 325 F. Supp. 781 (M.D. Ala. 1971) 53 through Birnbaum’s theory.187 Instead of suing the state on behalf of the workers, Dean filed a class-action lawsuit on behalf of the mental patients. He argued that the job cuts deprived the patients of their constitutional right to treatment as defined by Birnbaum. Dean’s questionable motives did not deter others acting on behalf of the patients to capitalize on the opportunity.

Judge Frank Johnson, an Alabama judge who read about Birnbaum’s theory, decided to put it to the test himself.188 Dean invited Birnbaum and Charles Halpern to join his legal team. Halpern also brought on Bruce Ennis, who worked for the New York Civil Liberties Union and would be a key figure in a later case, Donaldson v O’Connor.189 Dean used sensationalistic stories to demonstrate the horrendous conditions at Alabama state hospitals, and Judge Johnson was shocked by the evidence. In 1972, he ordered the state to overhaul the entire hospital system and ruled that civilly committed mental patients “unquestionably have a constitutional right to receive such individual treatment as will give each of them a realistic opportunity to be cured or to improve his or her mental condition.”190 Legislators begrudgingly approved additional funding and rehired of all the fired workers plus two hundred more. More importantly, Birnbaum’s doctrine was upheld in a federal court of law.

Judge Johnson was not only integral to a victory for patient rights, but the reason Wyatt even made it out of legal limbo. Johnson’s ruling shaped future mental health litigation, and his actions at this critical juncture were deeply influenced by his exposure to the Civil Rights

Movement. He initially gained notoriety in Alabama for joining the majority on a three-judge panel striking down the Montgomery bus-segregation law. In his decision, Johnson heavily relied

187 Pete Earley, Crazy: A Father’s Search Through America’s Mental Health Madness, (New York: The Berkley Publishing Group, 2006), 154-156. 188 id 189 422 U.S. 563 (1975) 190 Jeffrey D. Fields, "O'Connor v. Donaldson," Hofstra Law Review, Vol. 4: (Iss. 2, Article 10), 1976, 514, http://scholarlycommons.law.hofstra.edu/hlr/vol4/iss2/10 54 on the principle established in Brown v. Board of Education that separate but equal facilities were violations of the due process and equal-protection clauses of the 14th Amendment. He used that same reasoning to order the desegregation of public schools, parks, libraries, museums, airports, restaurants, and all manner of other public places throughout Alabama. In 1965,

Johnson gained national attention when he issued an order allowing Dr. Martin Luther King Jr. to march from Selma to Montgomery. In his obituary in 1999, the New York Times spoke of

Judge Johnson with awe. The author wrote, “The judge's decisions were legion: He cleared the way for registering black voters, outlawed poll taxes, struck down state laws barring blacks and women from jury service, expanded the right of the poor to court-appointed lawyers, and issued the first court order for legislative reapportionment in the nation's history … As a federal judge, he often made controversial decisions that lower state courts refused to make.”191

Johnson’s experience judging matters in the Civil Rights Movement enabled him to see a similar phenomenon occurring in Wyatt, compelling him to hear the case. He then used similar reasoning to uphold the rights of the mentally ill that he used to uphold the rights of African-

Americans. In both scenarios, Johnson recognized how a government process played a role in repressing a minority. He perceived the illegality and unconstitutionality of this suppression, and in both cases ruled in favor of the minority. More importantly, Johnson’s decisions made the broader acknowledgment that a group of stereotypically marginalized people did indeed have rights, and those rights were to be defended. Johnson’s involvement in major Civil Rights

Movement cases and Wyatt exemplifies how African-American activists paved the way for

Americans to reconsider minority rights.

191 Robert McFadden, “Frank M. Johnson Jr., Judge Whose Rulings Helped Desegregate the South, Dies at 80,” New York Times, 24 July 1999, http://www.nytimes.com/1999/07/24/us/frank-m-johnson-jr-judge- whose-rulings-helped-desegregate-the-south-dies-at-80.html 55

Chapter 5: Two Movements Intersect through Bruce Ennis

The anti-psychiatry literature introduced in the early 1960s shook the medical and lay communities’ faith in a once infallible institution. The Civil Rights Movement, and the 1960s in general, laid a crucial foundation for the reevaluation of who deserved rights in America. Bruce

Ennis’s involvement in both Wyatt v Stickney and Donaldson v O’Connor highlights how these two distinct movements dovetailed to finally bring about the collapse of the asylum system.

In 1957, Kenneth Donaldson was involuntarily committed to Florida State Hospital at

Chattahoochee, with a diagnoses of paranoid schizophrenia. He was not considered dangerous to himself or others, but was still confined against his will for almost 15 years. During that time, he rarely saw a doctor and received virtually no treatment.192 His confinement was a “simple regime of enforced custodial care.”193 Donaldson aggressively resisted his commitment, insisting he was not sick and should be released. He wrote letters to various members of Congress detailing the poor conditions of Chattahoochee, hoping to explain his situation and secure release. In 1961,

Donaldson’s persistence convinced the Florida legislature to investigate Chattahoochee. The committee described Donaldson’s building as “antiquated, completely obsolete, and a serious fire hazard.” The hospital was severely understaffed, and Donaldson’s section had no psychiatrist, no psychologist, no nurse, and only one doctor (an obstetrician) responsible for

1,000 male patients. What few attendants it had frequently resorted to beating and choking. The vast majority of patients spent years sitting and standing around a large locked warehouse, with no diversions or true treatment.194 The report was dismal, yet had virtually no impact on the

192 Fields, "O'Connor v. Donaldson," 512 193 Bruce J. Ennis, Prisoners of Psychiatry: Mental Patients, Psychiatrists, and the Law, 1st ed. (New York: Harcourt Brace Jovanovich, 1972), 89. 194 id 88 56

Florida legislature. They refused to fund even a single new position.195 Donaldson’s unrelenting stream of letters to the Governor’s office was equally ineffective, prompting no change in

Chattahoochee’s standards. The legislative and executive branch reacted with indifference to

Donaldson’s plight. Instead, he had to turn to the judiciary to defend his civil rights.

Donaldson read Birnbaum’s article in 1960, and reached out to the lawyer. Birnbaum agreed to represent Donaldson and brought Ennis on the case as well, having worked with him during Wyatt. Together, they helped Donaldson file a class action suit against the Florida hospital and its Superintendent, Dr. J.B. O’Connor. The suit was on behalf of all the patients at

Chattahoochee, and alleged that they were not receiving adequate treatment. However, Birnbaum and Ennis had radically different goals in mind. As Thomas Szasz pointed out with chagrin,

Birnbaum’s entire theory revolved around how patients had a constitutional right to treatment within a hospital.196 Birnbaum was not fighting for the rights of mentally ill individuals to exist outside the hospital system, but to have adequate care while confined. Birnbaum actually demonstrated a similar faith to the reformers explored in Chapter 3. In his original “Right to

Treatment” article, Birnbaum stated, “It should be realized that the average present-day public mental institution, even if only for custodial care, is a radical improvement over pre-public mental institutional care and past public mental institution care.” 197 Birnbaum still believed that a mental institution was the best place for someone with a mental illness to be sent, even as he was demonstrating how poorly they were run.

Birnbaum’s ideas seem a contradiction. He recognized the unconscious stigmas working against the mentally ill, as his entire “sanism” theory was based on society’s persistent and

195 id 196 Szasz, Psychiatric Slavery, 57-58 197 Birnbaum M., "The Right to Treatment," 500 57 systematic rejection of the mentally ill. Like Belknap, he knew it was not coincidence that there had never been enough money in the hospital system. He even predicted that it was not probable the situation would be resolved in the near future, and it was more likely the “average inmate of a public mental institution would continue to receive inadequate treatment.”198 He admitted state hospitals would probably continue to worsen and operate as a “wastebasket for the chronic severely mentally ill.”199 He was aware of the exposés of the past and their failure to enact real change, quoting Deutsch and citing the same Harry Solomon speech as the 1961 Joint

Commission on Mental Health (however he omitted the portion where Solomon calls for hospitals to be liquidated).200 Nonetheless, like so many reformers before him, Birnbaum was still trying to improve the asylum, not remove any patients from it. His right to treatment theory, developed and published before the massive wave of anti-asylum literature, was very much a product of faith in mental asylums. He hoped that his right to treatment would usher in “the dawn of a new day for the state mental hospital as a vital, integral, and necessary part of the therapeutic mental health continuum.”201 He questioned the asylum’s functionality and teetered on the edge of asking for their abandonment, but in the end settled for better conditions.

Bruce Ennis, on the other hand, represented the next generation of mental health advocates. Born 15 years after Birnbaum, he married the Civil Rights Movement and anti- asylum sentiment. Ennis began his career working at a large Wall Street firm litigating on behalf of corporations. One night, he watched a televised debate featuring Aryeh Neier. Neier was then the director of the New York Civil Liberties Union, the New York affiliate of the American Civil

Liberties Union. The NYCLU and its parent organization, the ACLU, were based on protecting

198 id 199 Birnbaum M.,“The Right to Treatment: Some Comments on its Development,” 99 200 Birnbaum M., “The Right to Treatment,” 500 201 Birnbaum M.,“The Right to Treatment: Some Comments on its Development,” 98 58 the individual rights and liberties of American citizens, and thrived in the anti-establishment atmosphere of the 1960s. From 1954 to 1964, the organization had what ACLU historian Samuel

Walker called its most successful decade in its history.202 Membership more than doubled from

30,000 to 80,000,203 and by 1970 affiliates had spread from seven states to 46.204 Their defense of civil liberties helped systematically overturn repressive government laws, most notably those enforcing legalized segregation. The ACLU submitted an amicus brief for Brown v Board, provided legal assistance for the Freedom Rides in 1961 and the integration of the University of

Mississippi, and represented hundreds of protesters arrested while demonstrating in the South.205

Additionally, the ACLU defended draft protesters in Tinker vs Des Moines Independent

Community School District (this case was especially important because it established that the government could not create “enclaves” such as schools or prisons where all rights are forfeit),206 religious minorities in Engel v Vitale, women in Griswold v Connecticut, and LGBTQ individuals in 1965 when the San Francisco Police shut down an LGBTQ fundraiser.207 They were also behind several cases promoting prisoner rights and the rights of the criminally accused, such as Mapp v Ohio, Gideon v Wainwright, and Miranda v Arizona. The ACLU and its affiliates had a clearly established goal of protecting individuals from repressive government institutions.

Ennis was moved by Neier’s debate and the NYCLU’s mission, and volunteered to do pro bono litigation with them. He embraced the principles of the organization so wholeheartedly

202 Samuel Walker, In Defense of American Liberties: A History of the ACLU, 2nd ed. (Carbondale: Southern Illinois University Press, 1999), 219 203 id 217 204 id 262 205 id 263-264 206 id 260 207 “ACLU History: Earliest Advocacy on Behalf of LGBT People,” American Civil Liberties Union, September 1, 2010, https://www.aclu.org/other/aclu-history-earliest-advocacy-behalf-lgbt-people 59 that he soon asked Neier for full-time employment. In 1970, the NYCLU spearheaded the Mental

Patients’ Rights Project, and Neier recommended Ennis apply to direct it. Ennis accepted, and began working full-time for the NYCLU as Director of the Mental Health Division.

Ennis was not only working in a group centered on promoting civil rights, but an entire era uniquely focused on the issue. Just as the focus on minority oppression primed Birnbaum to think about mental patients in a new way, so Ennis approached the mentally ill with a perspective steeped in civil rights. He understood the phenomenon that Birnbaum coined sanism, and how it alienated most people from the mentally ill. A reporter asked him in 1974, “Do you think there is any hope of bringing this issue to the attention of the people, appealing to their humanity?” Ennis replied,

“No, none at all. I think most people don’t like ‘mental patients.’ They don’t like anyone whom they cannot categorize neatly into an acceptable niche that is comfortable for them. I think if it were put to a popular referendum, the people in this country would favor massive custodial warehouses where people are swept off the streets and kept for the rest of their lives and drugged, tranquilized, shocked, whatever is necessary to keep them off the streets.”208

Ennis and Birnbaum shared a comprehensive understanding of the negative stigma working against the mentally ill, and how it manifested in rejection and oppression.

However, the crucial difference between the ideas of Ennis and Birnbaum was the dawn of anti-asylum literature. Where Birnbaum developed his theory in the late 1950s, Ennis did not even enter the field of mental health until anti-asylum literature had been circulating for a decade. Ennis only started researching mental health when he began his job as director of the

Mental Patients’ Rights Project in 1970. While doing so, he came across the popular anti-asylum literature of the time. Some of his first information on mental health came from Thomas Szasz

208 Leonard Roy Frank, “Interview with Bruce Ennis,” Madness Network News 2, no. 5 (1974): 10. 60 and his writings on “the myth of mental illness.”209 In fact, Ennis credited Szasz as a major influence who shaped his entire approach to the mentally ill. Exposure to such anti-asylum literature meant that Ennis was not viewing the mentally ill in the same light as Bly, Beers,

Deutsch, or even Birnbaum 15 years prior. Those reformers were operating in a world where the asylum enjoyed justification by silence. Ingrained faith in the model prevented them from even considering options other than pouring more money into the system. Ennis, on the other hand, broached the mental health scene at a time when authors were questioning the very foundation of the asylum. This profoundly changed Ennis’s point of view, and tainted his opinion of the public mental hospital system. He developed a vehement opposition to involuntarily commitment, and sought to shut down the institutions altogether. In a 1974 interview, he stated that his personal goal was “nothing less than the abolition of involuntary hospitalization.”210 Initially, Ennis opposed asylums so strongly that he would not participate in any right to treatment court cases, including the Wyatt lawsuit. He explained,

"I refused to do so because I was afraid if [lawsuits based on the right to treatment] were successful...it would become a legitimizing stamp on involuntary confinement, another basis for depriving people of their liberty.... I think that the only thing that makes sense is to talk about a ‘right to refuse treatment.’ In other words, I don't really believe in the 'right to treatment' concept."211

Ennis personified the intersection of two very distinct movements, and the result was a new wave of anti-psychiatry, anti-involuntary commitment attorneys determined to use the judicial system to expand patient rights.

Birnbaum and this new generation clashed on a fundamental level, and this rift was evident as early as Wyatt. Birnbaum’s daughter remembered that during the Wyatt case, her

209 Rothman, The Willowbrook Wars, 50 210 Frank, “Interview with Bruce Ennis,” 10 211 id 61 father tried to include a challenge to the Medicaid exclusion of the mentally ill. Birnbaum felt that federal reimbursement would incentivize the right to treatment to be implemented effectively. However, according to Birnbaum, “The other principal attorneys of the Wyatt case, who held a civil libertarian view, refused to include this challenge because they believed that the state hospital systems should be abolished.” 212 These kind of arguments were frequent, and caused the majority of litigation to proceed on a compromise basis. The civil libertarians acknowledged that the United States was not ready for a complete abandonment of the hospital system. But, forcing states to provide more resources and spend more money on patients could be justified because it created a disincentive to unnecessary institutionalization. Ennis claimed the only reason he eventually took the Wyatt case was because he saw the right to treatment as

“the best method for de-institutionalizing thousands of persons.” He explained he had been given

“Some advance information that the judge in that case [Johnson] would not only say that there is something in the abstract called the ‘right to treatment,’ but that he would set standards so high that the State of Alabama literally would not be able to meet them … instead of hiring more psychologists Alabama was going to have to discharge many of the residents in its institutions.”213

Ennis disagreed with the theoretical basis of right to treatment, but was willing to use it to achieve deinstitutionalization.

Birnbaum never intended for his right to treatment theory to be used to shut down state mental hospitals, and resented the civil liberties groups for misusing his theory. 214 Eventually, the arguing between the lawyers became so bitter that Birnbaum resigned from the Wyatt team in

1972. Halpern, Friedman, and Ennis returned to Washington and founded the Mental Health Law

212 Birnbaum R., “My Father’s Advocacy for a Right to Treatment” 213 Frank, “Interview with Bruce Ennis,” 10 214 Earley, Crazy, 159 62

Project. 215 The new firm took over the Donaldson case that Birnbaum initiated, and by the end of the first year it had also filed class-action suits against hospitals in Nebraska, Tennessee, Maine,

South Carolina, North Carolina, and Virginia. These suits operated with the explicit purpose of deinstitutionalization, and the firm relied on the same strategy they used in Wyatt. They argued that Birnbaum’s right to treatment theory required states to provide patients with adequate treatment, then demanded the state legislatures spend millions of dollars to renovate their hospitals. Most legislatures were either unwilling or unable to meet such standards, and instead voted to shut down their institutions. In this way, the Mental Health Law Project hoped to orchestrate widespread deinstitutionalization. Ennis and the civil libertarians never intended for

Kenneth Donaldson or any other citizen to receive treatment inside the hospital. Right to treatment was simply a legal means to an end, and that end was the right to live outside a mental hospital.

The decision in Donaldson was key to this overall strategy. In 1971,

Donaldson successfully sued Florida State Hospital and Superintendent O’Connor for denying him adequate treatment. A jury ruled in his favor and awarded compensatory and punitive damages. A court of appeals affirmed the initial ruling in 1974, holding that a person

“involuntarily civilly committed to a state mental hospital has a constitutional right to receive such individual treatment as will give him a reasonable opportunity to be cured or improve his condition.”216 O’Connor and the hospital took the case all the way to the Supreme Court, which in 1975 did not outright affirm the appeal’s decision or Birnbaum’s right to treatment. Instead, it issued a very narrow interpretation. The Supreme Court held, “A State cannot constitutionally

215 The Mental Health Law Project would later be renamed the Bazelon Center for Mental Health Law, after Judge Bazelon. 216 Fields, “O'Connor v. Donaldson," 512 63 confine without more a non-dangerous individual who is capable of surviving in freedom by himself or with the help of willing and responsible family members or friends.”217 While the decision was more narrow than he had initially hoped, Ennis still considered the case a success.

In an interview immediately after the trial, he explained that the decision meant, “Mental hospitals as we have known them can no longer exist in this country as dumping grounds for the old, the poor and the friendless.” Such institutions, he said, “will have to re-evaluate the status of each patient.”218 Donaldson himself was released, and nonviolent civilly committed mental patients could no longer be held solely because they had a mental illness.219

Just as Brown v Board did not immediately solve discrimination, the decisions made in

217 id 513 218 Warren Weaver Jr., “High Court Curbs Power to Confine the Mentally Ill,” The New York Times, June 27 1975, http://www.nytimes.com/1975/06/27/archives/high-court-curbs-power-to-confine-the-mentally- ill-if-not-dangerous.html 219 Bruce Ennis was instrumental in the deinstitutionalization of the mentally ill, and he later used his experience in Wyatt and Donaldson to enact similar change for persons with developmental disabilities. During Wyatt and Donaldson, Ennis visited Chattahoochee and a handful of Alabama mental hospitals. He witnessed first-hand the poor conditions patients were kept in, and was deeply affected. Personally troubled by the treatment of individuals with mental illnesses, Ennis came to realize that a similar situation was occurring in state institutions for the developmentally disabled. In 1972, in what would become his most sensational and well known case, Ennis filed a class- action lawsuit on behalf of the 5,400 residents of the Willowbrook State School for Mentally Disabled Children in Staten Island. Willowbrook was the largest state-run institution for mentally handicapped children in the country, and was notorious for its wretched conditions. After Ennis initiated the case, journalist Geraldo Rivera published video footage of developmentally disabled children being strapped to beds, tied to benches, and lying naked on the floor in their own feces. The public was outraged, and Ennis capitalized on the shocking evidence. He used the same tactics and arguments to demand change for the children at Willowbrook that he used to demand change for Kenneth Donaldson and the patients in Alabama hospitals. After a protracted legal battle, in 1975 Ennis and the NYCLU finally procured a consent decree mandating significant reforms. In 1983, the state of New York announced the closure of Willowbrook. By 1987, all children had left the school and it permanently closed. Furthermore, the Willowbrook case significantly contributed to the passage of the Civil Rights of Institutionalized Persons Act in 1980. A second wave of deinstitutionalization swept the country in the 1980s, this time of institutions for the developmentally disabled. Ennis continued to prosecute on behalf of the mentally ill and developmentally disabled until his death in 2000. For further reading on Ennis’s involvement with the developmentally disabled, see The Willowbrook Wars by David and Sheila Rothman. 64

Rouse, Wyatt, and Donaldson did not result in an immediate closing of asylums. Rather, collectively the rulings made it unambiguous that persons with a mental illness retained basic civil rights. They were confirmed as citizens who could lay claim to the constitution and its protections. This acknowledgement of indispensable human rights caused any remaining rationale behind asylums to unravel. There was no longer a justification for relegating the mentally ill to decrepit asylums with no control over their own fate. The right to basic treatment inside a hospital almost immediately evolved into the right to refuse treatment, and the right to exist outside a hospital.

The court cases in the late 1960s and early 1970s were a crucial supplement to the anti- asylum literature of the early 1960s. They gave concrete, legal force to the abstract theories postulated by Goffman, Szasz, Scheff, and Foucault. Between their works, President Kennedy’s federal push towards community care, and Ennis and the civil libertarians’ continued class action suits, mental hospital populations swiftly and steadily dropped. The decade from 1955-1965 had experienced a modest decline in patient populations. But from 1970-1986, hospital populations dropped from 413,00 patients to 119,000.220 Even more importantly, hospital admission rates began to decline for the first time in 1972. The shift away from the asylum system that Kennedy called for in 1963 was finally becoming a reality a decade later.

220 Grob, The Mad Among Us, 291 65

Conclusion: Why Combination was Key

Mental hospital admissions continued to decline, as did total hospital populations. By

1994, only 71,619 patients resided in state hospitals.221 By the 21st century, hospital populations had stabilized at around 35,000 patients.222 This sweeping change was only possible through the combination of the anti-psychiatry movement and the Civil Rights Movement. The revolutionary writings of Goffman, Scheff, Foucault, and Szasz proposed that it was not the implementation of asylums that was flawed, but that the model itself was defective. The very consideration that society should pursue an option other than asylums was unprecedented, and opened the system to vulnerability. At the same time, the Civil Rights Movement shifted the locus of social change from paternalistic guardians working through the legislature on a minority’s behalf, to oppressed groups demanding their own rights in front of the judiciary. African-American activists sparked a national reassessment of what minorities were entitled to. This changing attitude allowed patients such as Donaldson to utilize the judiciary to defend his rights, and the rights of all mentally ill patients. It also led key figures such as Birnbaum, Halpern, and Johnson to reclassify the mentally ill as full-fledged citizens with rights that needed to be respected. They recognized that the mentally ill were not all dangerous “others” who needed to be put away to protect society, but equal citizens whose rights were being denied by a government institution.

Internal pressure from the anti-psychiatry literature and external pressure from the Civil

Rights Movement merged to create an overwhelming force capable of toppling the asylum

221 E. Fuller Torrey, Out of the Shadows: Confronting America’s Mental Illness Crisis (New York: John Wiley & Sons, 1997), quoted in “Deinstitutionalization: A Psychiatric Titanic,” Public Broadcast System, 10 May 2005, http://www.pbs.org/wgbh/pages/frontline/shows/asylums/special/excerpt.html 222 Ana Swanson, “A Shocking Number of Mentally Ill Americans End Up in Prison Instead of Treatment,” Washington Post (Washington, D.C.), April 30, 2015, https://www.washingtonpost.com/news/wonk/wp/2015/04/30/a-shocking-number-of-mentally-ill- americans-end-up-in-prisons-instead-of-psychiatric-hospitals/?utm_term=.48b431093673 66 system. Yet neither movement would have led to deinstitutionalization without the other.

Without the judicial precedent set by black activists, the anti-psychiatry faction would have had no vehicle with which to enact tangible change. More importantly, without the Civil Rights

Movement demanding a national reevaluation of minority rights, there would have been no parallel reevaluation of the mentally ill’s place in society. It was well-known that the “separate” facilities for African-Americans were inferior. Schools, movie theaters, restrooms, and libraries designated for African-Americans were dilapidated, run-down, and problematic. But to the rest of society, this did not matter because African-Americans were considered second-class citizens.

African-Americans were not entitled to their full rights, and so the oppression was justified.

Analogously, Goffman and the others could have pointed out how asylums were inherently flawed and would always fail. But without that critical reevaluation of rights driven by Civil

Rights Movement, it would not have mattered. Because the mentally ill were not considered full citizens, they were not entitled to their full rights. Society would have justified their confinement in the same way it justified inferior facilities for African-Americans. The anti-psychiatry needed the Civil Rights Movement to move forward towards deinstitutionalization.

Conversely, without the anti-psychiatry movement, classifying the mentally ill as genuine citizens would only have led to better treatment inside the hospitals. Had Goffman and the other authors not first weakened faith in the asylum model, the inevitable response to any reevaluation of rights would have been simply pouring more money into asylums. This is best illustrated by

Morton Birnbaum’s attitude. Birnbaum sincerely considered the mentally ill as oppressed citizens being denied their rights. He fought vigorously on their behalf, but his way of doing this was ensuring their adequate treatment while confined in a hospital. Birnbaum was heavily influenced by Civil Rights Movement, but that alone did not lead him call for 67 deinstitutionalization. Only through anti-psychiatry weakening society’s faith in asylums and the

Civil Rights Movement highlighting the oppressed status of the mentally ill did deinstitutionalization occur.

The anti-asylum movement and the Civil Rights Movement complemented each other, and this is best seen through the work of Bruce Ennis. He acknowledged that the mentally ill were being oppressed, and that their rights were being infringed on. But then he went further than any other reformer and called for the abandonment of the system. He tied the oppression of the mentally ill to the asylum model itself. Ennis taking over the Donaldson case from Birnbaum symbolized the old guard, who fought to improve asylums, giving way to a new guard of anti- asylum civil libertarians. Ultimately it was this new generation, wedding the movements of anti- psychiatry and Civil Rights, that brought about the collapse of the American asylums system.

68

Epilogue: Where Are We Now?

Today, insane asylums are so far removed from modern medicine that they have been relegated almost exclusively to the realm of horror movies and other aspects of popular culture.

Abandoned, decaying facilities are surrounded by local ghost stories of sadistic doctors and nurses, and patients who suffered gruesome deaths. 223 Popular articles list the “creepiest” haunted hospitals that thrill-seekers can explore if they dare.224 Building on the tradition of The

Snake Pit and One Flew Over the Cuckoo’s Nest, countless TV shows, movies, and books utilize the insane asylum setting and inhabitants to frighten the audience.225 In fact, Universal Studios annual event “Halloween Horror Nights” has used the fictional Shady Brook Rest Home and

Sanitarium as a haunted house at least seven times.226 The haunted asylum trope plays on the enduring fear society has of the mentally ill, and for that reason it is unlikely to disappear.227 Its continued use in pop culture reinforces the notion that mental hospitals are terrifying, inherently evil facilities. Many people, especially of the younger generation, have formed their conception of mental hospitals solely from these media representations. As a result, the real-life experiences of patients have been exaggerated and sensationalized to the point where asylums are associated overwhelmingly with fear and dread.

Surely this depiction rings true for patients like Kenneth Donaldson, who considered his

223“Shante Cosme, “The 10 Craziest Mental Asylums in America,” Complex, January 23 2013, http://www.complex.com/pop-culture/2013/01/crazy-mental-asylums/byberry-mental-hospital 224 Andy Campbell, “These Photos of Abandoned Asylums Will Keep You Awake Tonight,” Huffington Post, September 4 2013, http://www.huffingtonpost.com/2013/09/04/abandoned-asylums- photos_n_3866248.htmlb 225 American Horror Story, Ghost Hunters, Shutter Island, The Ward, Sucker Punch, and Batman’s frequent ventures to Arkham Asylum are just a few. 226 “Halloween Horror Nights,” Universal Studios, http://www.halloweenhorrornights.com. 227Torie Bosch, “The Horror Trope that Won’t Die: Haunted Mental Hospitals,” Slate, July 8, 2011, http://www.slate.com/blogs/browbeat/2011/07/08/the_horror_trope_that_won_t_die_haunted_mental_hos pitals.html 69 time in Chattahoochee akin to a horror movie. He and the civil libertarians would also consider it a victory that since 1955, over 97% of psychiatric beds have been removed from state hospitals.228 Modern legislation prohibits involuntary commitment in all but the most extreme circumstances, mainly criminal cases or immediate and certain danger to oneself. In the sense that deinstitutionalization shut down the vast majority of state hospitals, it was a resounding success.

However, if the broader goal of the movement was to improve life for the mentally ill, the results are much more problematic. Critics of deinstitutionalization like psychiatrist Darold

Treffert warned as early as 1974 (before the Supreme Court even ruled on Donaldson) that the civil libertarians had gone too far. He pointed to the story of Angela and Rene, two young women in college. One evening, the pair spent several hours mutely staring at each other on a public street corner, seemingly “in a trance.” The police arrived and took the women to a nearby station for questioning. Their “bizarre” behavior was unnerving, but not illegal. Showing neither homicidal nor suicidal tendencies, they did not legally qualify for psychiatric observation, and so the police were forced to let them go. Thirty hours later, the two lit each other on fire as part of a suicide pact. Angela suffered burns on over 20% of her body, but lived. Rene died. In another case, a 19-year-old woman recovering from schizophrenia was released from the psychiatric ward of a general hospital mere days after she attempted suicide. Doctors said her situation lacked the element of “extreme likelihood of immediate harm to herself or others,” and as such she was released without further treatment. She hung herself the next day.

To Treffert, these examples demonstrated deinstitutionalization’s morbid legal triumph.

228 Dominic Sisti, Andrea Segal, and Ezekiel Emanuel, “Improving Long-term Psychiatric Care: Bring Back the Asylum,” Journal of the American Medical Association, 2015; 313(3):243-244. doi:10.1001/jama.2014.16088, http://jamanetwork.com/journals/jama/fullarticle/2091312 70

He explained, “In our zeal to protect basic human freedoms, we have created a legal climate in which mentally ill patients, and sometimes the people around them, are ‘dying with their rights on.’” By this, he meant that in all three cases, civil rights were fastidiously observed and due process respected. Many would applaud the fact that the women involved were not automatically locked away in a “loony bin” at the first sign of aberrant behavior. Nonetheless, the result of this rights-centered policy was death and injury.

Treffert condemned a callous mindset that seemed single-mindedly focused on upholding rights, even at the cost of a person’s life. However, in a nuanced and well-researched argument, he did not recommend a return to the hospitals of the 1940s and 1950s. He acknowledged that for every person who would have been “saved” by involuntary commitment, there existed “a little old immigrant who, though perfectly sane, has been institutionalized for years because of his broken, unintelligible English was mistaken for psychotic ramblings.” Or somewhere else, an

“elderly woman, labeled retarded in the 1920s and shuffled to a forgotten ward … [who was] in fact a genius.” He assured readers his intent was not to “minimize the grievous harm done in such situations.” However, he did firmly believe that in “championing a cause they deeply believe in, [the civil libertarians’] zeal may have exceeded their judgement.”229 He urged the medical community to seek “reasonable middle ground between protecting the right of the psychiatric patient to remain free –a precious and important right- and protecting the right of both that patient and those around him or her from tragic and untoward effects of the patient’s illness.”230

As shown by Treffert, people were not spontaneously cured of their mental illnesses just

229 Darold Treffert, “Dying with their Rights On,” American Journal of Psychiatry, 130:1041 (September), 1973. 230 id 71 because asylums disappeared. No triumphant happy ending occurred where most patients were suddenly able to live “normal” lives in their community. This was indeed the case for some, like

Donaldson. To these individuals, deinstitutionalization was a welcomed release from a life of unjust confinement. But for many people with a serious mental illness, the collapse of the asylum system meant the evaporation of any social safety net. Despite optimistic predictions, the community care President Kennedy envisioned replacing asylums never materialized. The 1963

Community Mental Health Act was intended to create 1,500 community care centers. Paul

Appelbaum, a psychiatry professor and mental health law expert, explained that of these, only half were ever built and not a single one was fully funded.231 Mental hospitals were slowly but surely phased out, but no community centers arose to replace them. Gerald Grob summarized the result this had on the mentally ill. He wrote,

In a large number of cases individuals were discharged from mental hospitals, only to be thrust into a setting that was not necessarily conducive to their welfare. The theoretical emphasis on the right to least restrictive treatment, moreover, was hardly relevant to cases involving individuals unable to care for themselves and for whom there was no known treatment. Indeed, critics of institutionalization, precisely because they discussed the issue of involuntary commitment largely in terms of abstract individual rights, avoided the far more difficult talk of evaluating theory in the light of concrete situations that rarely offered clear-cut moral choices.232

Left with nowhere to turn, many individuals (like the women mentioned by Treffert) died due to lack of treatment. A great many more ended up homeless. As of 2015, one in four homeless adults staying in shelters had a serious mental illness. Almost half had a mental illness and/or substance use disorders.233 Others ended up in jail. In 2009, 20% of inmates in jails and 15% of

231 “Kennedy’s Vision for Mental Health Never Realized,” USA Today, October 20 2013, http://www.usatoday.com/story/news/nation/2013/10/20/kennedys-vision-mental-health/3100001/ 232 Gerald Grob, "Doing Good and Getting Worse: The Dilemma of Social Policy," Michigan Law Review 77, no. 3 (1979): 782, doi:10.2307/1288148, https://www.jstor.org/stable/pdf/1288148.pdf 233 Dustin DeMoss, “The Nightmare of Prison for Individuals with Mental Illness,” The Huffington Post, March 25, 2015, http://www.huffingtonpost.com/dustin-demoss/prison-mental-illness_b_6867988.html 72 inmates in state prisons had a serious mental illness. This totaled approximately 356,000 inmates, more than ten times the 35,000 patients remaining in state hospitals.234 The three largest mental health providers in the USA are currently jails: Cook County in Illinois, Los Angeles County, and Riker’s Island in New York City. Once in jail, many prisoners suffering from mental illness find their condition exacerbated and amplified by incarceration without treatment, especially when sent to solitary confinement.235 This leads to considerably higher recidivism rates among the mentally ill, and much longer stays in jails.236 What ultimately has happened is not progress, but a trans-institutionalization of the mentally ill from asylums to homeless shelters and prisons.

Society seems to have come full circle. Allies of the mentally ill are once again Dorothea

Dix in 1843, lamenting the fact that the mentally ill perish in prison or on the street.

Interestingly, America even seems poised to begin the whole cycle again. 237 Frustrated with the failure of the status quo, some doctors and psychiatric experts are calling for a “rehabilitation of the ill-reputed institution of the psychiatric asylum.”238 In 2015, a paper in the American Medical

Association Journal made its recommendation quite clear in the title alone: “Improving Long-

Term Psychiatric Care: Bring Back the Asylum.” The authors explained that the decrease in psychiatric beds since the 1970s has made “few high-quality, accessible long-term care options available for a significant segment of the approximately 10 million US residents with serious mental illness … the void is both ethically unacceptable and financially costly.”

234 “How Many Individuals with Serious Mental Illness are in Jails and Prisons?” Treatment Advocacy Center, November 2014, http://www.treatmentadvocacycenter.org/storage/documents/backgrounders/how%20many%20individual s%20with%20serious%20mental%20illness%20are%20in%20jails%20and%20prisons%20final.pdf 235 DeMoss, “The Nightmare of Prison for Individuals with Mental Illness” 236 id 237 Sisti, “Improving Long-term Psychiatric Care” 238 Hanna Kozlowska, “Should the U.S. Bring Back Psychiatric Asylums?” The Atlantic, 27 January 2015, https://www.theatlantic.com/health/archive/2015/01/should-the-us-bring-back-psychiatric- asylums/384838/ 73

These authors were well aware of the notorious abuse that plagued asylums in the past.

The main advocate, Dr. Dominic Sisti, acknowledged, “Long-term psychiatric treatment has been viewed with suspicion, and rightly so.”239 However, he and his associates still advocated for a return to the “original” psychiatric asylum, a “new kind of refuge in which mentally ill persons could live and heal, built on principles of humane and moral treatment … a protected place where safety, sanctuary, and long-term care for the mentally ill would be provided. It is time to build them- again.”240 They insist these new asylums will be a radical departure from the “snake- pit” hospitals of One Flew Over the Cuckoo’s Nest. And maybe they will be. Yet, it is impossible not to hear the echoes of Beers, Wright, Maisel and Deutsch in their clarion calls for newer, better-funded asylums. The reformers of the 1940s and 1950s were just as self-assured as Dr.

Sisti that their hospitals would be different from the “hell-holes” of the past. Whether Sisti and his fellow researchers could succeed where reformers of the past failed is impossible to say.

Mental health is a thorny issue that does not have a simple right or wrong answer. However, what will undoubtedly fail is a simple return to the past. If this new wave of reformers believes that adding a fresh coat of paint to the walls, paying attendants a little more per hour, and improving the food will solve the problem, their efforts will be as futile as those that came before them. Only through a thorough understanding of why the asylum system collapsed in the 1970s can this new wave of reformers hope to make real improvements, and spark genuine progress in society’s treatment of the mentally ill.

239 Kozlowska, “Should the U.S. Bring Back Psychiatric Asylums?” 240 Sisti, “Improving Long-term Psychiatric Care” 74

References Primary Sources

Bazelon, David L. "Implementing the Right to Treatment." The University of Chicago Law Review 36, no. 4 (1969): 742-54. doi:10.2307/1598973.

Beers, Clifford W. A Mind that Found Itself: An Autobiography. Garden City: Doubleday, 1908.

Belknap, Ivan. Human Problems of a State Mental Hospital. New York: Blakiston Division, 1956.

Birnbaum, Morton. "The Right to Treatment." American Bar Association Journal 46, no. 5 (1960): 499-505. http://www.jstor.org/stable/25721181.

Birnbaum, Morton. “The Right to Treatment: Some Comments on Its Development” in Medical, Moral, and Legal Issues in Mental Health Care. ed. Frank J. Ayd. Baltimore: Williams & Wilkins, 1974: 97-141.

Burris, Donald S. The Right to Treatment: A Symposium. New York: Springer Publishing Company, 1969.

Bly, Nellie. Ten Days in a Mad-House. New York: Ian L. Munro Publisher, 1887.

Darwin, Charles. The Descent of Man, and Selection in Relation to Sex. Princeton: Princeton University Press, 1981. https://teoriaevolutiva.files.wordpress.com/2014/02/darwin-c-the- descent-of-man-and-selection-in-relation-to-sex.pdf.

Davies, Lawrence. “Mental Hospital Called Outmoded.” New York Times, May 13, 1958. http://journals.sagepub.com/doi/pdf/10.1177/107755875801500707.

Donaldson, Kenneth. Insanity Inside Out. New York: Crown Publishers, 1977.

Ennis, Bruce J. Prisoners of Psychiatry: Mental Patients, Psychiatrists, and the Law, 1st ed. New York: Harcourt Brace Jovanovich, 1972.

Foucault, Michel. Madness and Civilization: A History of Insanity in the Age of Reason. New York: Pantheon Books, 1965.

Frank, Leonard Roy. “Interview with Bruce Ennis.” Madness Network News 2, no. 5 (1974): 10- 15.

Galton, Francis. “Hereditary Talent and Character.” MacMillan’s Magazine 12, (1865): 157-166, 318-327. http://psychclassics.yorku.ca/Galton/talent.htm.

Goffman, Erving. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. New York: Anchor Books, 1961. 75

Halpern, Charles. “Escape from Arnold & Porter.” American Bar Association Journal Online, Feb. 1, 2008. http://www.abajournal.com/magazine/article/escape_from_arnold_porter.

Joint Commission on Mental Illness and Health. Action for Mental Health: Final Report of the Joint Commission on Mental Illness and Health 1961. New York: Basic Books, 1961.

Kennedy, John F. “Remarks on Signing Mental Retardation Facilities and Community Health Centers Construction Bill.” John F. Kennedy Presidential Library and Museum, October 31 1963. https://www.jfklibrary.org/Asset-Viewer/Archives/JFKPOF-047-045.aspx.

Kennedy, John F. “Special Message on Mental Illness and Mental Retardation.” John F. Kennedy Presidential Library and Museum, February 5, 1963. https://www.jfklibrary.org/Asset-Viewer/Archives/JFKPOF-052-012.aspx.

Kesey, Ken. One Flew Over the Cuckoo’s Nest. New York: Signet, 1962.

Maisel, Albert Q. “Bedlam 1946.” Life Magazine, May 1946. http://mn.gov/mnddc/parallels2/prologue/6a-bedlam/bedlam-life1946.pdf.

McFadden, Robert. “Frank M. Johnson Jr., Judge Whose Rulings Helped Desegregate the South, Dies at 80.” New York Times, 24 July 1999. http://www.nytimes.com/1999/07/24/us/frank-m-johnson-jr-judge-whose-rulings-helped- desegregate-the-south-dies-at-80.html.

Phillips, Derek L. "Rejection of the Mentally Ill: The Influence of Behavior and Sex." American Sociological Review 29, no. 5 (1964): 679-687. http://www.jstor.org/stable/2091418.

Scheff, Thomas. Being Mentally Ill: A Sociological Theory. Chicago: Aldine Publishing, 1966.

Sisti, Dominic, Andrea Segal, and Ezekiel Emanuel. “Improving Long-term Psychiatric Care: Bring Back the Asylum.” Journal of the American Medical Association, 2015; 313(3):243-244. doi:10.1001/jama.2014.16088. http://jamanetwork.com/journals/jama/fullarticle/2091312.

The Snake Pit. Directed by Anatole Litvak. 1948. Los Angeles, CA: 20th Century Fox.

Szasz, Thomas. The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York: Dell Publishing, 1961.

Szasz, Thomas. Psychiatric Slavery. New York: The Free Press, 1977.

Treffert, Darold. “Dying with their Rights On.” American Journal of Psychiatry, 130:1041 (September), 1973.

Ward, Mary Jane. The Snake Pit. New York: Random House, 1946). 76

Weaver, Warren Jr. “High Court Curbs Power to Confine the Mentally Ill.” The New York Times, June 27, 1975. http://www.nytimes.com/1975/06/27/archives/high-court-curbs-power-to- confine-the-mentally-ill-if-not-dangerous.html.

Wright, Frank L. Jr. Out of Sight, Out of Mind ... A Graphic Picture of Present-Day Institutional Care of the Mentally Ill in America, Based on more than Two Thousand Eye-Witness Reports. Philadelphia: National Mental Health Foundation, 1947.

77

Secondary Sources

“ACLU History: Earliest Advocacy on Behalf of LGBT People.” American Civil Liberties Union. September 1, 2010. https://www.aclu.org/other/aclu-history-earliest-advocacy- behalf-lgbt-people.

Birnbaum, Rebecca. “My Father’s Advocacy for a Right to Treatment.” The Journal of the American Academy of Psychiatry and the Law Online, March 2010. Vol. 38 Issue (1): 115-123. http://jaapl.org/content/38/1/115.

Black, Edwin, “Eugenics and the Nazis- The California Connection.” San Francisco Gate, November 9, 2003. http://www.sfgate.com/opinion/article/Eugenics-and-the-Nazis-the- California-2549771.php.

Black, Edwin. “Hitler’s Debt to America.” The Guardian, February 5, 2004. https://www.theguardian.com/uk/2004/feb/06/race.usa.

Bosch, Torie. “The Horror Trope that Won’t Die: Haunted Mental Hospitals.” Slate, July 8, 2011.http://www.slate.com/blogs/browbeat/2011/07/08/the_horror_trope_that_won_t_die _haunted_mental_hospitals.html.

Campbell, Andy. “These Photos of Abandoned Asylums Will Keep You Awake Tonight.” Huffington Post, September 4, 2013. http://www.huffingtonpost.com/2013/09/04/abandoned-asylums- photos_n_3866248.htmlb.

Choper, Jesse H. “On the Warren Court and Judicial Review.” Catholic University Lecture Review 17 (1967). http://scholarship.law.berkeley.edu/cgi/viewcontent.cgi?article=1255&context=facpubs.

Cosme, Shante. “The 10 Craziest Mental Asylums in America.” Complex, January 23, 2013. http://www.complex.com/pop-culture/2013/01/crazy-mental-asylums/byberry-mental- hospital.

Clooney, Nick. The Movies that Changed Us: Reflections on the Screen. New York: Atria Books, 2002.

DeMoss, Dustin. “The Nightmare of Prison for Individuals with Mental Illness.” The Huffington Post, March 25 2015. http://www.huffingtonpost.com/dustin-demoss/prison-mental- illness_b_6867988.html.

Deutsch, Albert. "Dorothea Lynde Dix: Apostle of the Insane." The American Journal of Nursing 36, no. 10 (1936): 987-97. doi:10.2307/3413570.

Earley, Pete. Crazy: A Father’s Search Through America’s Mental Health Madness. New York: The Berkley Publishing Group, 2006. 78

Farber, Steven A. “U.S. Scientists’ Role in the Eugenics Movement (1907-1939): A Contemporary Biologist’s Perspective.” Zebrafish, 2008 Dec: 5(4): 243–245. doi: 10.1089/zeb.2008.0576. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2757926/.

Fields, Jeffrey D. "O'Connor v. Donaldson.” Hofstra Law Review, Vol. 4: (Iss. 2, Article 10), 1976. http://scholarlycommons.law.hofstra.edu/hlr/vol4/iss2/10.

Fishbein, Leslie. "The Snake Pit (1948): The Sexist Nature of Sanity." American Quarterly 31, no. 5 (1979): 641-665. doi:10.2307/2712430. http://www.jstor.org/stable/2712430?seq=3#page_scan_tab_contents.

Grob, Gerald. The Mad Among Us: A History of the Care of America’s Mentally Ill. New York; Free Press, 1994.

Grob, Gerald. "Doing Good and Getting Worse: The Dilemma of Social Policy.” Michigan Law Review 77, no. 3 (1979): 782, doi:10.2307/1288148. https://www.jstor.org/stable/pdf/1288148.pdf.

“Halloween Horror Nights.” Universal Studios. http://www.halloweenhorrornights.com.

“How Many Individuals with Serious Mental Illness are in Jails and Prisons?” Treatment Advocacy Center. November 2014. http://www.treatmentadvocacycenter.org/storage/documents/backgrounders/how%20man y%20individuals%20with%20serious%20mental%20illness%20are%20in%20jails%20an d%20prisons%20final.pdf.

“Kennedy’s Vision for Mental Health Never Realized.” USA Today, October 20, 2013. http://www.usatoday.com/story/news/nation/2013/10/20/kennedys-vision-mental- health/3100001/.

Kozlowska, Hanna. “Should the U.S. Bring Back Psychiatric Asylums?” The Atlantic, January 27, 2015. https://www.theatlantic.com/health/archive/2015/01/should-the-us-bring-back- psychiatric-asylums/384838/.

Kuhl, Stefan. The Nazi Connection: Eugenics, American Racism, and National Socialism. New York: Oxford University Press, 1994.

McAllister, Margaret. “Looking Back to See Ahead: Reassessing The Snake Pit for its Gothic Codes and Significant” in Peer Reviewed Proceedings: 6th Annual Conference, Popular Culture Association of Australia and New Zealand. ed. Philip Mountford. Wellington: PopCAANZ, 2015, 84-94. http://popcaanz.com/conferenceproceedings-2015/.

79

Paul, Diane B. “Darwin, Social Darwinism, and Eugenics.” Cambridge University Press, 2006. http://www.dianebpaul.com/uploads/2/3/2/9/23295024/darwin_social_darwinism_and_eu genics.pdf.

Pye, A. Kenneth. “The Warren Court and Criminal Procedure.” Michigan Law Review 67, no. 2 (1968): 249-268. http://scholarship.law.duke.edu/cgi/viewcontent.cgi?article=5627&context=faculty_schol arship.

Rostow, Eugene. “The Democratic Character of Judicial Review.” Harvard Law Review 66, no. 2 (1952): 193-224. http://digitalcommons.law.yale.edu/cgi/viewcontent.cgi?article=3158&context=fss_paper s.

Rothman, David and Sheila Rothman. The Willowbrook Wars. New York: Harper & Row, 1984.

Scull, Andrew. Madness in Civilization: A Cultural History of Insanity. Princeton: Princeton University Press, 2015.

Swanson, Ana. “A Shocking Number of Mentally Ill Americans End Up in Prison Instead of Treatment.” Washington Post (Washington, D.C.), April 30, 2015. https://www.washingtonpost.com/news/wonk/wp/2015/04/30/a-shocking-number-of- mentally-ill-americans-end-up-in-prisons-instead-of-psychiatric- hospitals/?utm_term=.595ae22f46bc.

Talbott, John A. The Death of the Asylum: A Critical Study of State Hospital Management, Services, and Care. New York: Grune & Stratton, 1978.

Taylor, Steven. Acts of Conscience: World War II, Mental Institutions, and Religious Objectors. Syracuse: Syracuse University Press, 2009.

Torrey, E. Fuller. Out of the Shadows: Confronting America’s Mental Illness Crisis. New York: John Wiley & Sons, 1997. Quoted in “Deinstitutionalization: A Psychiatric Titanic.” Public Broadcast System, 10 May 2005. http://www.pbs.org/wgbh/pages/frontline/shows/asylums/special/excerpt.html.

Walker, Samuel. In Defense of American Liberties: A History of the ACLU, 2nd ed. Carbondale: Southern Illinois University Press, 1999.