The story of American deinstitutionalization has become familiar. In a long arc—from President Kennedy’s Community Mental Health Act of 1963 to the present—federal and state governments dismantled mental asylums and released the psychiatrically disturbed into the world. Though there were sometimes brutal abuses in the state mental hospitals of the early twentieth century, the closure of the asylums did not put an end to mental illness. If anything, with the proliferation on the streets of psychosis-inducing drugs such as methamphetamine, the United States has more cases of serious mental illness than ever before—and less capacity to treat and manage them.
The question now is not, “What happened to the asylums?” but “What replaced them?” Following the mass closure of state hospitals and the establishment of a legal regime that dramatically restricted involuntary commitments, we have created an “invisible asylum” composed of three primary institutions: the street, the jail, and the emergency room. In slaying the old monster of the state asylums, we created a new monster in its shadow: one that maintains the appearance of freedom but condemns a large population of the mentally ill to a life of misery.
I’ve spent the better part of two years looking at this invisible asylum in West Coast cities. In major metropolitan areas such as Los Angeles, San Francisco, and Seattle, the scale of mass psychosis is overwhelming, and the inadequacy of the public response is self-evident. It’s difficult, if not impossible, to imagine how public officials could “solve” the problem of mental illness in these places, which are home to tens of thousands of individuals suffering from the “perilous trifecta” of mental illness, addiction, and homelessness. By contrast, the contours of the problem are much more intelligible, even manageable, in smaller cities and towns.
Olympia, Washington—a city of 52,000 tucked between a joint military base and a state forest—is one such place. In Olympia, approximately 250 individuals have become entangled within this broken system of care, cycling through the streets, the local jails, and the emergency ward at Providence St. Peter Hospital. A half-century ago, many, if not most, of these wayward souls would have been institutionalized. In 1962, Washington State had 7,641 state hospital beds for a total population of 2.9 million; today, it has 1,123 state hospital beds for a population of 7.6 million—a 94 percent per-capita reduction.
In the absence of the old asylums, Olympia’s mentally ill are now crowded into a city-sanctioned tent encampment, then shuffled through the institutions of the modern social-scientific state: the jail cell, the short-term psychiatric bed, the case-management appointment, the feeding line, and the needle dispensary. In the name of compassion, we have built a system that may be even crueler than what came before.
It’s 8 AM, and the streets of Olympia are at low tide. After months of coronavirus lockdowns, all the businesses in the downtown core have shut down, with some restaurants, salons, and tattoo shops boarding up their windows altogether. The only people remaining are those with nowhere to go: the homeless, the mad, and the addicted.
Patrol Sergeant Amy King and Officer Patrick Hutnik, who oversee the downtown area for the Olympia Police Department, take me on a tour. The officers are working their morning rounds, rousting awake people sleeping in doorways and asking them to move on. We see a slumped-over man who has soiled himself overnight, a man wrapped in cardboard complaining that his tent got stolen, and three women behind a barricade of shopping carts and filthy blankets. One of the women is tying off her arm with a blue rubber strap but loosens her grip when she sees us; the other two are barely cognizant, blinking at the officers and lifelessly nodding their heads.
The cast of characters in Sergeant King’s world is a difficult one. Hai air-fights through the streets because he believes monsters in the ground want to enter his body. Michael, an old man, calls 911 many times per day but doesn’t qualify as “gravely disabled.” Suburban Gary lives in a broken-down Chevy Suburban full of trash but refuses all offers of housing or services. And John, wheelchair-bound and covered in sores, huffs paint in front of officers because he knows he’s “untouchable”—the hospital will not take him, the prosecutor will not move on his criminal cases, and the psychiatrists cannot send him for involuntary treatment.
Following the downfall of the old regime of state asylums, local jurisdictions have had to create their own makeshift mental-health systems. In Olympia, as a growing population of mentally ill and addicted individuals began to overwhelm downtown, the city council decided to open the “mitigation site,” a publicly funded tent encampment for 150 residents. In theory, the site would provide centralized shelter and access to services; in practice, it functions as an open-air asylum—with none of the protections of the old hospitals.
Brandon, who helps manage the mitigation site for the City of Olympia, tells me that the people arriving here are “in the gutter.” He estimates that 95 percent have a substance-abuse disorder and nearly 100 percent have a mental-health condition. Though the city continues to distribute glossy photos from the site’s opening day, the reality on the ground is grim—open drug use, fighting, crime, and even a tent filled with used needles. Brandon says that “thousands of rats” have tunneled under the site and will chew through the wooden pallets beneath the tents and the plastic walls of the tiny homes. “There’s soy in the plastic,” he explains. “It’s like candy to rats.”
By ordinance, the city provides mitigation-site residents with basic social services and some access to care. Sean, a resident recently released from prison in Idaho, landed at the site and got a prescription for bipolar disorder “on the spot.” He shows me a plastic freezer bag filled with bottles of carbamazepine and duloxetine, and explains his predicament: “I found out, after 40 years, that I was bipolar. I lost relationships, job, marriage. Now I’m trying to put everything back together.”
But for most other residents, there is no treatment or recovery—only the punishing routine of the needle, the pill, and the breakdown. The city’s police force has nicknamed the mitigation site “The Thunderdome,” after the dystopian Mad Max movie, because of the raucous nights, with residents yelling, overdosing, and assaulting one another. One former resident said that her boyfriend kept her imprisoned in a tent there, plied her with methamphetamine, and put a knife to her throat when she tried to leave—all under the supposed supervision of city officials.
As they finish their morning rounds and head back to the station, Sergeant King and Officer Hutnik find a disheveled, shirtless man, passed out with his body extending into the street. Officer Hutnik politely wakes him, and the man, known as Angry Marty, begins screaming about zombies and food lines down at the mission. He manically gathers metal piping tubes from the ground and bangs them into a shopping cart. “There is going to be a mob that finally takes over this city!” he screams. “They’re going to kill you! They’re going to kill you!”
Under the current policy regime, this madness has become an eternal recurrence: the officers will see Marty again tomorrow morning, as he suffers through another drug-terror, and they must leave him to fend for himself.
As we head back to the station, we can still hear Marty’s cries in the distance.
“Is that compassion?” Sergeant King asks, disappearing into the doorway.
The Olympia Municipal Jail is the second link in the city’s invisible asylum. It’s a small, doughnut-shaped building tucked behind a Japanese garden, with white and blue stucco walls. The jail has 36 beds, but the city generally won’t hold more than 28 inmates at a time because the old HVAC system can’t handle full capacity.
After checking in at the front desk, Officers Holmes and Esselstrom take me through the facility. They show me the intake desk, the single-stall shower, and the suicide-watch room. They lead me through the narrow hallways and flip open the steel viewing windows, so I can see the men and women inside the cells.
I ask the officers how many of the inmates suffer from mental illness. Officer Esselstrom says that they conduct an intake interview for every inmate and that “at least 90 percent” say that they have been diagnosed with a mental illness or have recently received psychiatric care. The officers explain that they see the same faces, over and over, often for the same crimes. “Some people have 40 different booking photos,” says Officer Holmes, explaining that the officers sometimes play a game in which they listen to the police radio and try to predict who will come to the jail based on the nature of the call, crime, and location.
Hannah is one of the inmates who has returned frequently over the past year. She walks up to the metal visitation grate with some hesitation, but after she learns that I’m not a representative of the courts, she tells me her story in a rapid-fire monologue. Hannah grew up in Auburn, California, and says that she was abandoned by her parents, and then abused by her grandmother. She was diagnosed with ADHD as a preteen, and after a series of fights and “explosive behavior” in high school, she was re-diagnosed as bipolar. She says she got pregnant at 17, then lost the baby when she rolled her car and the seatbelt crushed her stomach—which sent her life into a spiral. Over the next four years, she started using methamphetamine, checked in and out of psychiatric facilities, and then came to Olympia “to start over.”
That plan fell apart, too. For the past year, Hannah has lived on the streets and at the mitigation site with her boyfriend, a man twice her age and “a drug dealer and a pimp.” According to Hannah, they have been involved in a long-running domestic dispute—knives, choking, biting, drugs—and, despite mutual restraining orders, she always goes back to him because “it’s hard to say no when he shoves meth in my face.” Today, she has dirty hair and cracked skin, but it’s easy to see that she was once beautiful. Officers told me that her mother once came looking for her and brought an old high school portrait of Hannah with long hair and intricate makeup—but when the mother eventually found the daughter on the streets, she told everyone that Hannah was her boyfriend’s responsibility and promptly left town. Now Hannah is stuck on the streets and, when her methamphetamine addiction and bipolar disorder manifest as violence, she ends up in the city jail.
Such stories are commonplace. Across the United States, the jails have become de facto psychiatric hospitals. Bruce Gage, lead psychiatrist for the Washington State Department of Corrections, estimates that 20 percent to 30 percent of state prison inmates suffer from serious mental illness. The Monroe Correctional Complex outside Seattle, with nearly 500 beds for the mentally ill, is now the second-largest psychiatric facility statewide; only Western State Hospital is larger. “It used to be called deinstitutionalization,” Gage recently told the Seattle Times. “Now it’s called trans-institutionalization. We took everyone out of the state hospitals, and they pretty much, the same population, ended up in prisons and jails.”
This transition from asylum to prison has reached an astonishing scale. According to a study of 18,000 inmates in the Washington State prison system, 44 percent of inmates were determined to have mental-health disorders and 51 percent to have substance-abuse disorders—and 31 percent had both diagnoses simultaneously. Even the old flagship, Western State Hospital, has become a predominantly carceral environment, planning to accept only “forensic patients” who can no longer be held safely in state prisons.
The irony is devastating: as a society, we recoiled from the old asylums, but we have built in their place a parallel system that serves the same function, often under even more brutal conditions. We have adopted a new moral logic that says, “You have the right to be mad, but if you follow that madness to its logical conclusion, there is a prison cell waiting for you.” Under the weight of a cultural revolution against the asylums and civil rights lawsuits against involuntary commitment, a prison sentence has become the easiest option. The mentally ill get subsumed into the criminal class.
The final link in the invisible asylum is the psychiatric emergency room. In Olympia, this means Providence St. Peter Hospital, home to an 18-bed psychiatric unit that functions as the first stop for people coming off the streets in crisis. According to Sue Beall, the hospital’s director of behavioral health, the emergency psychiatric department receives approximately 500 people a month presenting symptoms of acute mental illness and substance-abuse disorders.
Beall describes the hospital as “overwhelmed.” The number of patients seeking emergency psychiatric care has risen rapidly in the past few years, and the hospital frequently operates beyond its regular capacity, issuing “single bed certifications” and allowing people to rest on cots in the hallways and mats on the floor. The severity of the cases has increased, too. Beall estimates that, as recently as a few years ago, only 20 percent of patients needed inpatient treatment; now that figure is between 50 percent and 60 percent. The result: doctors, nurses, and support staff are “spread too thin” and burning out under the pressure of the city’s “revolving door” of addiction, psychosis, and emergency care. Emergency rooms throughout the region are so pressed with mentally ill patients that doctors have adopted a policy of “treat ’em and street ’em”—that is, get patients medically stabilized and out as fast as possible, to prepare for the next onslaught.
To reduce the burden on emergency providers, the City of Olympia recently hired a Crisis Response Unit to patrol the streets and build relationships with the most seriously mentally ill. The team—six men and women in matching aqua-blue shirts—is headquartered in an open loft space on the second floor of a downtown storefront. According to program coordinator Anne Larsen, the Crisis Response Unit engages in more than 250 contacts a month, offering case management, referrals to services, and even transportation to medical appointments. Yet despite some successes—a woman placed into permanent housing, another living with her sister on the Eastside—the team spends most of its time managing a population of a few hundred mentally ill and addicted people who continually cycle through their care.
When I arrive in the Crisis Response Unit’s offices, the team is gathered around an old laptop and problem-solving some of their most difficult cases. They’re talking through the file for Eddie, who was living with his mother in rural Pacific County until she couldn’t handle his mental illness, packed him up in an Airstream trailer, and dropped him off on the streets of Olympia. Eddie began hoarding trash in his trailer, increased his drug use, and rapidly deteriorated. Eddie’s sister recently came looking for him and, together with the crisis response team, tracked him down on the streets. They’re trying to petition the court for a Joel’s Law detention—a form of involuntary commitment for drug psychoses—but they have hit a bureaucratic roadblock.
According to the crisis workers, it’s very hard to get any kind of involuntary detention. Larsen says that the Crisis Response Unit requests only one psychiatric hold evaluation per month, on average, because the standard is so high and varies so widely from doctor to doctor. The people on the streets, most of whom have gone through repeated evaluations, have rehearsed the answers that will get them immediately released: “I’m not a danger to myself or others, I know where I can sleep, I know where I can get food.” When I ask the team how difficult it is to get a long-term involuntary commitment at Western State Hospital, their response is unanimous: “Impossible.”
In total, according to the latest available data, designated crisis responders filed 1,599 petitions for involuntary holds in Thurston County, and the courts approved only 411 cases for inpatient detention—and the vast majority of these were for short-term, 14-day holds. To illustrate how challenging it is to secure an involuntary commitment, crisis workers told me that they once found a woman eating a dead rat in an alleyway, but this did not qualify her as “gravely disabled”; the reaction from relevant officials was that “at least she’s eating.”
The mentally ill end up playing a game of cat and mouse with the authorities. Jeremiah, a 32-year-old man in recovery from bipolar disorder and alcohol and methamphetamine addiction, told me that he would run wild in the streets: “I would be screaming at traffic, jumping up and down on cars, yelling and cussing at families, saying their kids are my kids.” At the end of one vodka-fueled bender, Jeremiah passed out on the train tracks and lost both his arms to the heavy steel of a freight locomotive. Even after his accident, the police department and crisis response team spent years trying to get Jeremiah help, following him through a series of short-term emergency visits, psychiatric evaluations, and stints in the municipal jail.
Finally, something changed. Larsen, the program coordinator, pulled every lever at her disposal and organized the entire apparatus of local government to pressure Jeremiah into accepting treatment. It took a massive mobilization—involving a hospital ward, an evaluation center, a jail term, two treatment programs, a halfway house, a street intervention, and a warrant hearing—but eventually Jeremiah relented. I asked him what had changed, and he said: “I called my mom on Mother’s Day from jail. I wanted to do something with my life.”
Jeremiah now stays at a recovery home on the edge of town. When I visit him there, he says that he has been sober for more than a year. “It’s my longest time clean since I was 11 years old,” he says. Jeremiah still distrusts authorities—when I took out my notebook, he asked if I was trying to get him recommitted—but acknowledges that he wouldn’t have gotten clean without the intense pressure of the local government. “Treatment was necessary,” he says, “even if I didn’t like how it came to me.”
In 1961, French theorist Michel Foucault reenvisioned the history of mental illness in his book Madness and Civilization, which documented the role of confinement, morality, and medicine from the Middle Ages to modernity. Foucault yielded some profound insights, but, like his radical-progressive American counterparts, he savaged the practice of confinement without proposing a substantive alternative.
Nearly 60 years later, it has become clear that the liberationists of the 1960s did not usher in a new era of freedom but something far darker. By reducing the entire cultural history of madness to one long progression of brutality, imprisonment, and false care, they laid the political groundwork for deinstitutionalization. At the same time, their insistence that mental illness was a “myth,” that it could be cured by new psychiatric drugs, or that it would be transformed through political consciousness turned out to be wrong.
Today, a consensus is emerging that deinstitutionalization went too far. In Washington State, a bipartisan coalition of legislators has implemented the beginnings of a reform agenda. In the past few years, the legislature has added acute substance-abuse disorder as a condition for involuntary treatment, extended the initial involuntary hold period from 72 hours to five days, and adopted plans to add 844 new inpatient psychiatric beds across the state. The state mental-health budget has nearly doubled in recent years, with widespread support from both Democratic and Republican lawmakers.
Do these reforms go far enough? Probably not. Washington hopes to increase its psychiatric bed capacity to 1,763 beds by 2025, or 23 beds per 100,000 residents. While that’s a significant increase from the current baseline, the goal still falls far short of the historical average of 263 beds per 100,000 at the height of the asylum period. Though advances in psychiatric drugs and outpatient treatment could reduce the total need for inpatient beds, it’s illusory to believe that we can operate at 9 percent of the capacity of the 1960s. For anyone who has witnessed the great masses of the mad wandering the streets of American downtowns, it’s obvious that our cultural and legal intransigence against confinement cannot hold.
Frontline workers in the current system understand this reality but hesitate to offer their full-throated endorsement of rebuilding the hospitals. When I ask Sergeant King for her opinion on the need for more involuntary psychiatric beds, she replies cautiously. “I have to be careful. I don’t want my words twisted,” she says, calibrating her language in order to avoid the charge of “criminalizing” mental illness. “I think we were too restrictive in the past, but we’ve swung the pendulum too far in the other direction.”
Perhaps what’s most needed is a renewed theoretical defense of the principles of the asylum—safety, rest, morality, and health—that Foucault and his compatriots demolished. This does not mean a return to the historical practices of the asylum but a revival of the spirit that animated the care and moral reasoning of the old retreats and hôpitaux. It is a moral scandal that our society, which has surpassed the material wealth of the nineteenth century 16-fold, cannot provide an adequate sanctuary for the mad and the unmoored. It’s easy to condemn the horrors of the old state hospitals, but the horrors of the invisible asylum may exceed them.
In my short time on Olympia’s streets, I heard about a litany of abuses and indignities that occurred under our current regime—a disabled man whose feet are rotting off, a woman hunted down like prey, a woman waking up on top of a corpse.
But the neglect is even more heartbreaking. Whenever I consider today’s system, I see the awful silhouette of a young man crumpled across a restaurant ingress, bare-chested and overwhelmed with madness. He introduces himself as Harrison and, revealing a Hindu-style third eye tattooed on his forehead, rattles on about angels and demons. He points to Officer Hutnik and says: “I once cured you of an infection.” Then he picks up an old Rubik’s Cube from his pile and, twitching with feverish intensity, points to the white squares and says, “This is where you can find me anywhere in the universe.”
A more muscular system of care could help this haunted soul. After we say good-bye to him, Hutnik tells me that he remembers Harrison from his time as a correctional worker at the Thurston County Jail a decade ago. “It’s amazing how you see another side of people after they’ve detoxed and gone on medication in jail,” Hutnik says. And this is precisely the insanity of our current system: in fear of “criminalizing mental illness,” we have simply delayed care until the mentally ill engage in explicit criminality. We thus condemn legions of vulnerable people like Harrison to street, jail, or emergency room. Until we rebuild the physical capacity and moral strength to help them, nothing will change.
Originally published at City Journal.