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Psychological Horror or Saving Grace? The Surprising History of Asylums in America

Psychological Horror or Saving Grace? The Surprising History of Asylums in America

Something spooky started happening in American pop culture in the 1970s and 1980s. If you grew up listening to The Ramones, reading Stephen King, and watching horror or slasher movies from that period, you got a certain, psychological sense of what makes a story scary.


You know how it goes: characters slowly descend into "madness," becoming more and more dangerous to themselves or others until they end up strapped to a hospital bed or in a straightjacket, about to be given shock treatment, a lobotomy, or a frightening injection.


As we learn more about mental health, we're learning how to tell the difference between pop culture myths and reality—but many myths remain. Perhaps nothing has been as distorted through the modern horror lens as psychiatric hospitals, or, as they were once known, "asylums." Read on to learn more about the history of these institutions and how they work now.



Haunted? Terrifying? Or Something Else?


This time of year, especially, you see it on-screen: scenes of people wriggling in restraints or trying to run from maniacal doctors with scary-looking grins. A lone wheelchair sits at the end of a long-abandoned hall, rusting and covered with dust, then suddenly starts moving on its own.


Heck, you don't even have to leave it to your imagination or the flickering lights of the cinema. Haunted asylum tours draw hundreds, even thousands, of people into the crumbling halls of abandoned psychiatric hospitals. Why go to a boring old haunted house when you can experience the ultimate in horror—a mental hospital haunted by the ghosts of the tortured, "mad," and lost? Do you dare cross the threshold of some of "the most haunted places in America"?


Abandoned psychiatric institutions may or may not host spirits and ghosts, but they are certainly haunted. They haunt us with the memory of the very real suffering our ancestors caused—and that we still cause—by misunderstanding and mistreating people with mental health conditions. We can begin the work to cure this curse by learning more about the reality behind the myths.


Does Anyone Ever Actually "Lose Their Mind"?


Let's start our tour by dispelling the myth of why people go into a psychiatric hospital in the first place. The idea of "madness" in pop culture has little to do with the actual experience of mental illness and mental health recovery. Even people who experience a psychotic break don't "lose their minds" the way characters in movies do. Chronic mental health conditions don't condemn anyone to be stuck in the same state "forever"; in fact, they do the opposite. They are cyclical, relapsing disorders with symptoms that vary in intensity and duration.


While mental illness can be devastating and cause great suffering, it is only ever a small part of who a person is. It does not define a person or automatically tell us what the end (or even the middle) of their story is going to be. Recovery is always possible and with the right care, people can get through these episodes safely and get back to living happy, fulfilling lives. Often, a brief admission to a psychiatric hospital can be part of the recovery process.


It is true that people have suffered inside the halls of psychiatric institutions. Some of what we see in horror movies actually happened. People with mental illness have been chained, caged, beaten, and killed. Stripped of their rights, people housed in psychiatric institutions were often subjected to horrifying experimental treatments that left them scarred or even killed them.


But not only is this not what psychiatric hospitals are like now, it is not what they were like in the beginning, and it isn't what mental hospitals were meant to become. American asylums were originally built to be places of safety, healing, and compassionate care. They reflected the earnest desires of reformers to end the cycle of abuse and neglect and replace it with something else. And, for a while, they were—more or less—the good places they were intended to be.


The Origin of the American Psychiatric Hospital


Psychiatric institutions existed before America was founded. (London's Bethlem Hospital traces its origins to the Middle Ages.) However, very few were built in America's early years. There are a few exceptions, but these early institutions were designed as holding, not treatment facilities, and were generally seen as unnecessary. At that time, Americans with mental health conditions were often held in jails or restrained and secluded in family homes. It wasn't until the mid-1800s that Americans started building asylums in earnest, inspired by a new movement for reform.


After being horrified by the mistreatment of mentally ill female convicts at the East Cambridge Jail in 1841, Dorothea Dix decided to fight for change. Over the next two decades, she visited several states, touring their jails and almshouses, reporting her findings to state legislatures and advocating for the construction of asylums—humane care facilities for people with mental illness.


Dix and other reformers believed in "moral treatment"—that taking people out of dark, cramped rooms, placing them in peaceful pastoral settings, and treating them kindly would help them "regain their sanity." Nearly all of the earliest American institutions were built with this idea in mind, thanks to Thomas Kirkbride, who literally wrote the manual on how to build an asylum.


The Kirkbride Plan and the Healing Power of Architecture


In 1854, Kirkbride published a book describing what would later be called the "Kirkbride Plan," a method for building psychiatric hospitals that reflected his moral treatment ideals. He believed patients should feel nurtured and cared for as they would in an ideal home setting. He recommended interior architecture and design strategies that would make psychiatric hospitals feel more like home, up to and including what colors of paint he thought were the most calming.


Kirkbride believed in the healing power of nature and thought that asylums should be designed with nature in mind. He showed how asylums could be made to take in the maximum amount of fresh air and sunlight. He said they should be set on sprawling grounds and built so that patients would be treated to beautiful views out of nearly every window.


The list of American psychiatric hospitals designed according to the Kirkbride plan is impressive. Over 50 Kirkbride plan hospitals were built in the United States from 1848 to 1890, from Maine to California. Many hospitals that began as Kirkbride Plan hospitals are still active as treatment facilities, and some have even preserved the original Kirkbride buildings. These hospitals include:


  • Arkansas State Hospital in Arkansas
  • Austin State Hospital in Texas
  • Central State Hospital in Virginia
  • Cherokee Mental Health Institute in Iowa
  • Mendota Mental Health Institute in Wisconsin
  • Oregon State Hospital in Oregon
  • Osawatomie State Hospital in Kansas
  • Sheppard Pratt Hospital in Maryland
  • St. Elizabeths Hospital in the District of Columbia
  • Western State Hospital in Kentucky
  • Worcester State Hospital in Massachusetts


Many Kirkbride hospitals put patients to work at on-site farms and gardens, a practice that was believed at the time to be therapeutic. Other patient activities included art, music, and dance therapy. While not everything was idyllic—other interventions included hydrotherapy, in which patients were wrapped in wet sheets or left to soak in tubs for hours—most of the terrifying practices we associate with the horror of psychiatric hospitals didn't start until the 1900s.


When the Horror Really Began


When we think of the horrifying things that can happen in psychiatric hospitals, we tend to think of some very specific practices: electric shock treatment, lobotomies, forced sterilization, and other dubious experimental treatments like insulin shock therapy. The thing is, none of these practices came into existence until well after most American asylums were built.


The first lobotomy in the United States was performed in 1936. Electroconvulsive therapy (ECT), also known as "shock treatment," was invented in Italy in the 1930s and wasn't practiced in earnest in American psychiatric hospitals until the 1940s. Forced sterilization didn't begin in America until 1907. Insulin shock therapy (also known as insulin coma therapy), which killed many patients, was developed in the late 1930s.


The introduction of these horrific practices helped usher in the downfall of American psychiatric institutions. There were other issues, too. By the early 1900s, psychiatric hospitals had become dangerously overcrowded. Conditions continued to deteriorate until public outrage in the 1950s and 1960s led to the deinstitutionalization movement, the end of these terrifying "treatments," and the closure of hundreds of psychiatric hospitals.


The Fall of Institutional Mental Health Treatment


When President John F. Kennedy signed the Community Mental Health Centers Act in 1963, he ushered in a new age in American mental health treatment. His law created federal funding that states could use to build and maintain community mental health centers. Medicaid, which passed in 1965, created financial incentives for states to prioritize community-based over institutional treatment. In the following decades, psychiatric institutions closed in large numbers, while those remaining reduced the number of treatment beds they held.


Since then, new laws have made it harder to keep public psychiatric hospitals open. The 1990 Americans with Disabilities Act (ADA) made it illegal to discriminate against people based on disability. In the 1999 Olmstead ruling, the Supreme Court declared that the ADA made it illegal to segregate people with mental health conditions in inpatient institutions when they could be safely treated outside of them. These laws have motivated states to continue to shrink or close down the psychiatric institutions that once treated hundreds of thousands of patients in the United States every year.


What Inpatient Psychiatric Treatment Is Like Now


The restrictions on inpatient treatment created by these laws have transformed the focus of American psychiatric hospitals from long-term to short-term care. Psychiatric hospitals now specialize in acute treatment and stabilization. This means they discharge patients as soon as they are stable enough to be safely treated in community-based settings again. The average length of stay in psychiatric hospitals is now about 10 days.


Deinstitutionalization was made possible by modern psychiatric medications, especially anti-psychotic medications, which help people recover from psychotic episodes relatively quickly. Modern psychiatric hospitalization often focuses on getting a person stabilized on the right medications. Inpatient mental health treatment typically also includes group and individual therapy and therapeutic activities like art classes, exercise, and social and recreational activities.


Discharge planning begins the day a person is admitted. Mental health professionals now believe that long-term recovery should take place in outpatient and community clinics where people can receive medication, therapy, and rehabilitative services to help them improve their functioning while living at home. People are generally discharged from a psychiatric hospital as soon as it is determined safe for them to leave, with referrals to community providers to continue their care.

The Horror of Not Getting Inpatient Treatment

While movies, video games, and other popular media continue to show psychiatric hospitals as places of horror, what is truly disturbing is the fate of people who need inpatient mental health treatment but can't get it. The sad truth is that we have returned to the conditions that horrified Dorothea Dix in the mid-1800s. Our largest psychiatric institutions now are jails where hundreds of thousands of people with mental illness are incarcerated every year. Many people with severe and persistent mental illness who don't get jailed for petty offenses end up homeless instead.


Why does this happen? Mental health conditions, especially manic and psychotic episodes, can trigger symptoms and behaviors that get people in trouble with police. A combination of paranoia and delusional thinking can sometimes make people violent, though this is relatively rare. Most people with mental health conditions are not violent and are more likely to be victims than perpetrators of violence. The issues that bring people with severe mental illness in contact with police are typically non-violent, like drug- or alcohol-related offenses, disturbing the peace, loitering, vagrancy, trespassing, and petty theft. These issues are often related to homelessness. 


Without access to long-term care in an institution, and without adequate community mental health services, people with severe mental illness can become homeless. Without medications, therapy, and supportive services that help them maintain their finances, health, and homes, they can be evicted with nowhere else to go but the shelter or the street. As a result of being homeless, they have more contact with police. Once arrested and in jail, they often languish while they wait for court-mandated psychiatric evaluations at overcrowded public mental health institutions. Once they are released from jail, they often return to the streets, where the cycle begins again.




While movies, video games, and other popular media continue to show psychiatric hospitals as places of horror, what is truly disturbing is the fate of people who need inpatient mental health treatment but can't get it. The sad truth is that we have returned to the conditions that horrified Dorothea Dix in the mid-1800s. Our largest psychiatric institutions now are jails where hundreds of thousands of people with mental illness are incarcerated every year. Many people with severe and persistent mental illness who don't get jailed for petty offenses end up homeless instead.


We should never go back to the horrors of forced surgeries, restraints, seclusion, and abuse in psychiatric hospitals. Nor should we return to the days where admission to a psychiatric hospital was more like a life sentence. And while we can admire the compassionate intentions and humane vision of "moral treatment," we've learned a lot since the mid-1800s. We can do so much better now, and we should.


One reason deinstitutionalization has been such a mess is that we've never funded community mental health treatment at the level it needs to be funded. People simply can't get the care they need, so their symptoms worsen until they do something that puts them on the street or in jail. The Community Mental Health Centers Act, the ADA, and Olmstead set the stage for a better system, but we haven't built it yet. If we can make outpatient mental health treatment more accessible while also ensuring people can get inpatient mental health treatment when they need it, we can finally wake up from the nightmare and roll the credits on the horrors of mental health mistreatment in America.

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Stephanie Hairston, MSW
Posted on 10/26/2020 by Stephanie Hairston, MSW

Stephanie Hairston is a freelance mental health writer who spent several years in the field of adult mental health before transitioning to professional writing and editing. As a masters-level clinical social worker, she provided group and individual therapy, crisis intervention services, and psychological assessments. She has also worked as a technical writer for a medical software company and as an editor for a company that appeals denials of insurance coverage for behavioral health treatment. As a writer, she is motivated by the same desire to help others that brought her into the field of social work and believes that knowledge is one of the most essential recovery tools. She strongly believes in the mission of OpenCounseling and in making therapy accessible for everyone.