We Closed the Mental Hospitals. The Streets Became the Wards

From the article:

In 1955, American state psychiatric hospitals held 559,000 patients. As of 2023, the number was around 36,000. If you adjust for population growth, that’s a decline from roughly 340 beds per 100,000 people to fewer than 11. Over the same period, the number of Americans experiencing homelessness on any given night has climbed to 771,480, the highest figure since HUD began counting in 2007. Of the individuals counted, about one in three, met HUD’s definition of chronic homelessness: a disability plus at least a year without stable housing.

These two trends are not unrelated, and the refusal to connect them is one of the great policy failures of modern America.

The story usually starts with President Kennedy. In 1963, he signed the Community Mental Health Act, legislation animated by a decent impulse: the large state psychiatric institutions of mid-century America were often nightmarish. Patients were warehoused in overcrowded wards, subjected to restraints, given ice baths, and sometimes left to languish for decades. The exposé journalism of the era, from Albert Deutsch’s The Shame of the States to Geraldo Rivera’s 1972 broadcast from Willowbrook, showed the public what “institutional care” often meant in practice. The revulsion was justified.

The plan was elegant on paper. Close the asylums. Build 1,500 community mental health centers across the country where people could receive outpatient treatment, crisis intervention, and rehabilitation while living at home or in small group settings. The large institutions would empty; the community infrastructure would catch them.

Only about half the planned centers were ever built. None were funded to the level the original promise required. Kennedy was assassinated the same year he signed the act, and subsequent administrations did not sustain the commitment. The introduction of Medicaid in 1965 gave states a perverse financial incentive to discharge patients faster: Medicaid’s “Institutions for Mental Diseases” (IMD) exclusion prohibited federal reimbursement for psychiatric care in facilities with more than 16 beds, which meant states bore the full cost of every patient in a state hospital. Move those patients to smaller community settings or general hospitals, and the federal government would pick up a share. States obliged. They closed the hospital beds. They did not invest the savings in the community infrastructure that was supposed to replace them.

Here is what the 2024 JAMA Psychiatry meta-analysis by Rebecca Barry and colleagues found when they pooled 85 studies covering 48,414 individuals across high-income countries: 67 percent of people experiencing homelessness currently have a mental health disorder. The lifetime prevalence is 77 percent. Substance use disorders top the list at 44 percent, followed by antisocial personality disorder (26 percent), major depression (19 percent), bipolar disorder (8 percent), and schizophrenia (7 percent). The rates among men are even higher: 86 percent lifetime prevalence.

The clinical term is anosognosia, from the Greek for “without knowledge of disease.” Approximately 50 to 60 percent of people with schizophrenia have it to some degree, and about 30 percent have severe, chronic anosognosia. They do not believe they are ill. This isn’t denial in the psychological sense, the kind where you know what’s wrong but refuse to face it. It’s a neurological impairment linked to dysfunction in the brain’s frontal lobe, affecting the ability for self-reflection and metacognition. The person with severe anosognosia who hears voices and believes the government is monitoring their thoughts does not register these as symptoms. They register them as reality. Telling them they need medication is, from their subjective perspective, like a stranger telling you that your own perceptions are hallucinations and you should take drugs to make them stop.

But look at what has happened in the absence of those beds. We haven’t liberated people with severe mental illness. We’ve relocated them, from hospitals to sidewalks, jails, and emergency rooms. The question isn’t whether people with treatment-resistant schizophrenia and chronic anosognosia will be institutionalized. They already are. The question is whether they’ll be institutionalized in places designed to treat them or in places designed to punish them.

But the civil liberties argument has a blind spot. It treats refusal of treatment as an expression of autonomous choice without reckoning with the fact that in severe anosognosia, the capacity for that choice is critically impaired by the very illness in question. When a person with a gangrenous leg refuses amputation because they believe their leg is fine, we don’t simply respect that refusal and send them home. We recognize that their perception is compromised and act accordingly. The brain is an organ, and when it is severely impaired by schizophrenia in ways that destroy the capacity for self-recognition, the ethical calculus of “respecting autonomy” changes.

If you had a family member with severe schizophrenia, hallucinating on a street corner in February, refusing food and medication because they believed the food was poisoned and the medication was a government plot, what would you want the system to do?

Most people, across the political spectrum, would not want the system to hand them a pamphlet about available services and walk away. They would want someone to intervene, to get their family member off the street, into a warm, safe, clinical setting, and onto medication that could, over weeks or months, restore enough insight for them to begin making informed decisions about their own care.

That intervention barely exists in America today. We have the pharmacological tools: clozapine for treatment-resistant schizophrenia, long-acting injectable antipsychotics for patients whose illness derails medication adherence. We have the knowledge. What we lack is the political will to build the infrastructure, because sixty years ago we closed a system that was broken, replaced it with nothing adequate, and then reframed that failure as freedom.

The 152,000 chronically homeless Americans are not free. They are abandoned.

And every year we don’t build the treatment infrastructure they need, the bill comes due in emergency rooms, jail cells, and frozen bodies on sidewalks. We can argue about the design of the system, the scope of involuntary treatment powers, the funding mechanisms, and the oversight structures. Those are worthwhile arguments. But we should stop pretending that the status quo, roughly 36,000 psychiatric beds for a nation of over 340 million, represents a considered policy choice rather than a catastrophic failure of political will.

We closed the mental hospitals. The streets became the wards. It is long past time to build something better.