POLICY BRIEF The Abandoned Legacy of Dorothea Dix by Jordan Harris “Men of Massachusetts, I beg, I implore, I demand . Raise up the fallen; succor the desolate; restore the outcast; defend the helpless.” - Dorothea Dix Much about the world has changed in the 172 years since Dorothea Dix pled with the men of the Massachusetts Senate to aid the mentally ill. The condition of mental health treatment, which she had witnessed firsthand while visiting the East Cambridge Jail years earlier, had moved her to action. She committed the rest of her life to defending the helpless, and kick-started America’s moral treatment movement. In the century since her death, the Commonwealth of Massachusetts has rightfully exalted her to the status of a heroine, even as it has, like the rest of America, slowly dismantled her life’s accomplishments. Today’s policy prescriptions eerily mirror the ones that left Dix aghast, with prisons serving as de facto mental health facilities and both adequate treatment and justice nowhere to be found. Much needs to be done at the intersection of mental health and criminal justice reform to reverse this course both nationally and in Massachusetts. There are two issues currently before state government that can point the Commonwealth in a different direction. The first concerns Bridgewater State Hospital which, following a series of hard-hitting reports by The Boston Globe and the Disability Law Center promised a handful of policy changes1, but have yielded little transparency and seem no closer to fulfilling the long-desired goal of transitioning the facility to Department of Mental Health oversight. The second concerns the practice of solitary confinement, which has come under heavy scrutiny from activists and experts, and was picked up for review by the state legislature on October 15th, 2015.2 The current status of both policy items does not match the ethos of Dix’s legacy. Institutionalization, Deinstitutionalization In 1840, a year before Dix began her advocacy work, the Treatment Advocacy Center and National Sheriff’s Association estimates that 20 percent of the nation’s jail and prison inmates were suffering from a form of mental illness.3 Many mentally ill inmates had neither the means nor the access to resources beyond the prison itself, with only one public psychiatric bed available for every Roe Better 5,000 Americans in 1850. Dix’s work led states to dedicate more resources to institutionalized treatment. She is directly credited with the creation and Government funding of more than 30 state psychiatric hospitals. Network Jordan Harris is a U.S. History Fellow at Pioneer Insititute and a graduate student at Harvard University. He holds a bachelor’s degree from Penn State University. June 2016 The Abandoned Legacy of Dorothea Dix In 1880, just a few years before Dix’s death, the Since the time of the CMHA, deinstitutionalization United States conducted one of the most thorough has led to the elimination of 90 percent of the surveys of the mentally ill in its history. It found that psychiatric beds at state hospitals around the country. over 40,000 mentally ill people had been moved to Today there is only one public bed for every 3,000 “hospitals and asylums for the insane” and less than citizens in the United States, a drop from one bed per 400 remained in jails and prisons nationwide.4 A 300 people in 1955. Some of this gap has been filled study in 1930 showed the low percentage remained by the growth of inpatient programs and general constant, near 1 percent, with studies through 1960 hospital psychiatric capacity, as well as private showing the same approximate figure.5 From 1843, psychiatric beds. Many factors, regardless of their when Dix issued her plea to the Massachusetts good intentions, have played a contributing role in legislature to “defend the helpless,” through 1960, the current state of mental health in correctional the United States virtually eradicated mental illness facilities, such as changes in mandatory minimum from jails and prisons, instead treating the afflicted sentencing laws and the previously referenced as patients. changes in civil commitment standards. In 2000, the American Psychiatric Association estimated that 20 By the mid-20th century, the state institutions that percent of prisoners in the United States experienced had been founded at Dix’s urging were plagued by some form of mental illness. Human Rights Watch decades of overcrowding, inadequate funding, and produced the same figure in 2003 based on interviews numerous failed treatment theories. The institutional conducted in state and local prisons.8 In 2006, the process came under heavy scrutiny from academics, Department of Justice conducted their own survey journalist, and others who were disgusted by the finding that 24 percent of jail inmates and 15 percent conditions inside psychiatric hospitals. Through the of state prison inmates “had at least one symptom of a 1950s and ‘60s the United States, like many Western psychotic disorder.”9 In 2014, the number of mentally nations, began the process of deinstitutionalization. ill prison inmates in Massachusetts state facilities The process was predicated on the belief that was estimated to be consistent with 20 percent community-based services and systems would be national figure.10 In 2012, the Massachusetts Sheriffs’ cheaper and more effective, and made possible in Association estimated that a whopping 42 percent of part by the growth of psychiatric drugs for treatment. county jail inmates have some form of mental illness, Changes in civil commitment laws over the course and 26 percent have a serious mental illness.11 of the decade, in a shift since labeled “a need for treatment model” to a “dangerousness model,” Attempts to improve the system have led to requiring that the individual being committed must numerous policy missteps, and failures to invest in pose an immediate danger to himself or others, helped the appropriate resources have created new issues to accelerate the deinstitutionalization and change and resuscitated old ones. Surveys conducted in the role of individual states played. President John F. various states by multiple organizations show that Kennedy saw the need to aid the move to community- the percentage of mentally ill citizens in America’s based treatment from the federal level, and in 1963 jails and prisons has returned to the same or a higher he signed the Mental Retardation Facilities and level than in 1840. It is as if Dorothea Dix, her heroic Community Mental Health Centers Construction Act work, and her accomplishments which improved the (CMHA).6,7 It quickly became clear that the CMHA lives of so many in Massachusetts and around the failed to properly serve the needs of individuals country, never existed. coming out of state hospitals, leaving many without the post-discharge support they needed. Only half the Bridgewater State Hospital community centers promised in the bill were ever Bridgewater State Hospital, which holds the unique built, and even those did not receive full funding. position of being a hospital run by a Department of Corrections, has been a frequent source of shame for 2 Pioneer Institute for Public Policy Research the Commonwealth of Massachusetts. The hospital to be moved by 1989, is now even higher. Patients became a national target during deinstitutionalization not convicted of a crime make up a majority of the thanks to its uniquely perverse practices when, prison’s population.18 In recent years, guards have in 1967, it was the subject of a documentary by been cited numerous times for failing to provide Frederick Wiseman.12 The documentary, Titicut proper treatment and improperly using restraints on Follies, showed guards humiliating and mistreating mentally ill patients, an issue at the center of Joshua prisoners and exposed how both guards and Messier’s 2009 death.19 Three guards involved with doctors failed to administer proper treatments. The the death were fired and have since been charged Commonwealth responded to the documentary with manslaughter. A pivotal 2014 report by the not with a call to leadership or sweeping changes, Disability Law Center concluded that guards are but by trying to have the film banned from public more concerned with punishment than patient care.20 viewing for over two decades. Before the film was set to be released at the 1967 New York Film A recent change, though not dealing directly with Festival, Massachusetts moved to block the public Bridgewater State Hospital, provides a hopeful showing, but was denied by the New York Supreme precedent. In July of 2015, as part of a supplemental Court. Following the festival, the Commonwealth budget item, Governor Charlie Baker allocated funds succeeded in blocking the documentary from being for the reopening of the Taunton State Hospital for shown in Massachusetts, with the Supreme Judicial the treatment of civilly committed women, formerly 21 Court ordering the film to be restricted everywhere.13 housed at MCI-Framingham. The move, which It would be 24 years before a Massachusetts Superior was first pledged by a state official in 1987, was a Court justice would finally lift the ban.14 The years central part of the Governor’s plan to combat opioid since have brought improvements in treatment, but addiction and signaled a recognition that treatment none have prevented the inefficiencies and additional could not properly be administered at a prison saying, embarrassing scandals for the hybrid hospital-prison. “We think it’s important that we find a way to get them treatment and not jail time.”22 This recognition can In the late 1980s, a string of deaths prompted national and should be extended to Bridgewater State Hospital, headlines at the hospital-prison, reported by The New which remains a black eye for Massachusetts, and York Times and a number of Nightline ABC episodes a shame to the Commonwealth’s legacy on mental which called for change.15,16 The complaints levied in health issues.