MAGA’s New Project: Making Asylums Great Again

On July 24, President Donald Trump signed an executive order that required states to begin institutionalizing people in hospitals or jails, regardless of capacity, and to lower the threshold for involuntary commitment. The directive — which targets “vagrancy” and “risks to the public” — reflects a bracingly anachronistic understanding of mental health care that evokes the age of Chester Arthur more than our own. But it was not the first sign of the administration’s Victorian attitudes toward mental illness. The Secretary of Health and Human Services, Robert F. Kennedy Jr., has long advocated the salubriousness of work camps, manual labor and exposure to the great outdoors as cures for a range of chronic afflictions. 

Democratic mayors and governors have also helped revive language last seen during the Gilded Age. Although crime rates are down in both New York and California, the appearance of crime and poverty has led Eric Adams and Gavin Newsom to express a 19th-century flavored fear and loathing of mental illness as a driver of urban crime. In October 2023, Newsom signed off on a revision of California’s involuntary commitment rules by appealing to a sense that community care has failed, and hospitals need to re-enter the picture. “The mental health crisis affects us all, and people who need the most help have been too often overlooked,” he said at the signing. “We are working to ensure no one falls through the cracks.”

This is a modern, progressive spin on an old script. Nineteenth-century Americans were obsessed with the perceived rise of mental illness and its connection to urban crime and public safety. “We now find him a raving maniac,” wrote Hinton Helper, a writer, white supremacist and failed gold miner, about an encounter in San Francisco in the early 1850s. “More than half naked, friendless and forlorn, he wandered about the streets. … Why, it may be asked, was there no public provision made for the removal and security of this pitiable nuisance?” Similar observations and complaints could be drawn from the dailies of every other American city. 

Prior to urbanization, colonial America dealt with mental illness as a community problem in largely informal, ad hoc ways. Sometimes this approach was benevolent, pooling funds to help pay for their care. It could also be more brutal: people without community ties could suddenly be expelled or disappeared into small jail cells. 

With the rise of cities, mental illness became more visible. Somebody in the midst of a psychotic break in a city was surrounded by strangers who felt threatened by their behavior; the older system of community care by family and neighbors no longer worked. Cities responded by building hospitals, such as Philadelphia’s Pennsylvania Hospital for the Insane. They resembled European institutions where patients were often left chained indefinitely to the walls. Incarcerated groups included homosexuals, people who displayed “excessive religiosity” and those suffering epilepsy, end-stage syphilis and dementia. 

The public display of mental illness contributed to a growing ambivalence toward cities by elites and social activists. Some concerns were tangible and medical, driven by disease outbreaks such as cholera. But the city was also a place where sexual mores broke down, revealing both promiscuity and venereal disease. Alcohol was readily available. Poverty was conspicuous and visible in ways that it hadn’t been among the rural poor a century before. Moreover, American cities were booming because of immigration, and Irish-Americans were disproportionately represented among the urban poor. Cut off from family ties and stereotyped as alcoholics, the Irish were seen as uniquely vulnerable to mental illness.

As with the current revival of interest in institutionalization, mental illness was seen as an issue of law and order, interwoven with the broader issue of poverty. One unique manifestation of this was the spread of so-called “ugly laws.” San Francisco led the charge with its 1867 law stating that “any person, who is diseased, maimed, mutilated or deformed in any way, so as to be an unsightly or disgusting object, to expose himself or herself to public view.” Other cities followed suit.

By the 1860s and 1870s, many states had established welfare boards that studied mental illness alongside poverty. Their conclusions were that crime and poverty were increasing so rapidly as to threaten the fabric of society, but that it could be remedied. In a report to the Massachusetts Board of State Charities, Samuel Howe said of the poor and ill: “All of them are open to outward influences; and that the best and ablest men should be called to care for them, and to devise ways and means for cutting off the sources whence those classes draw their recruits.”

Concurrently, attitudes toward treatment of mental illness were slowly shifting. Prior to the 18th century, mental illness was believed to be incurable. That changed with the advent of “Moral Treatment,” a vague idea that led doctors to model acceptable behavior for their patients through dialogue and action. 

In the United States, two reformers became particularly famous for championing Moral Treatment: Thomas Kirkbride and Dorothea Dix. Kirkbride was a Pennsylvania Quaker and the first superintendent of the Pennsylvania Hospital for the Insane. Kirkbride developed a whole system of hospital construction known as the Kirkbride Plan. One of the key pieces was a farm: at minimum, a successful hospital needed at least 100 acres of land. In one of his annual Reports of the Pennsylvania Hospital for the Insane, Kirkbride emphasized the importance of “free and systemic exercise in the open air, working at some trade, regular labor on the farm … all serve to break up nervous excitability.”

Dix was one of the most celebrated reformers of the century, traveling from state to state to investigate the treatment of people with mental illnesses. She recommended the construction of state hospitals almost everywhere and was a supporter of Kirkbride. In a report for the State of Pennsylvania, she made clear her feelings on cities, declaring the causative “causes of insanity in large cities” to be “numerous.” Tobacco, alcohol, bad diet, insufficient exercise, sex — all were possible causes of madness. Even hazardous work or business disappointments were thought to injure people’s minds. 

Farms became central to the whole system of state asylums that arose in the 19^th century. Some of this was practical: growing their own food made them cheaper to operate. But the labor itself was central to the period’s ideas of rehabilitation and health: work showed people how to live. The routine and discipline of outdoor labor was considered the precise opposite of chaotic urban life, the drudgery of factory work. Middle-class occupations were also suspect. Writing to officials in North Carolina, Dix claimed that “sedentary employments are not in general favorable to health.”

The result was an explosive growth in the number of “Kirkbride” hospitals. Seventy-three were built in the United States, and more in Canada. The same attitudes persisted in Britain and throughout Europe, where French reformers embraced so-called colonies agricoles (“agricultural colonies”) for juvenile delinquents and for asylums. 

This system was not as successful as its proponents might have hoped. Kirkbride boasted of high “cure” rates, and some patients did seemingly benefit from his system, but doctors frequently failed to keep track of readmissions and cherry-picked subjects. Even in terms of method, Moral Treatment varied wildly. “Sanity” was whatever seemed sane to the doctor. Ironically, doctors and administrators struggled with the question of foreign-born inmates. Some hospitals worked with them enthusiastically, while others tried to avoid them or set up separate wards for immigrants.

This hospital system ultimately faltered under increased demand. Booming hospital populations, a trend that continued into the last century, convinced many reformers that mental illness was actually incurable. So began the era of eugenics and mass institutionalization, in which the focus became segregating people away from the rest of the public and even sterilizing them to stop them from reproducing. Hospitals again rapidly overcrowded under this new ideology. The modestly sized Oregon State Hospital, founded as a Kirkbride institution, was home to 3,000 people by the 1930s, so overcrowded that people were housed in the gymnasium. 

It’s unlikely that Trump is familiar with Kirkbride or Dix, but both he and RFK Jr. are trafficking in a dangerous kind of false nostalgia, as are liberals who wax wistful for the time when people were swept off the streets and into institutions under questionable definitions of mental illness and theories of rehabilitation. As Trump deploys the National Guard in D.C. and threatens to do the same elsewhere, we may be on the verge of returning to a dark chapter in how we treat those who are seen as mentally ill or, as Trump’s executive order phrased it, “who pose a danger to others or are living on the streets and cannot care for themselves.”