Christopher Payne

An abandoned ward at Kankakee State Hospital, Illinois; photograph by Christopher Payne from his book Asylum: Inside the Closed World of State Mental Hospitals, 2009

In 1939 the British physician Lionel Penrose published an article that described an inverse relationship between prisons and asylums—the so-called Penrose Hypothesis. Widely respected in medical circles for his pioneering work on Down syndrome and other hereditary disorders, Penrose was better known for applying mathematical formulas to nagging social issues. Using statistics gathered from eighteen European countries, he determined that the convict population in a given locality went up or down depending on the number of occupied psychiatric beds. As one group grew in size, the other declined at a similar rate.

The article didn’t make much of a splash. A world war intervened, and Penrose moved on to other things. (His much-discussed Penrose Method, devised in 1946 to aid the formation of new international bodies, called for voting rights based on the square root of a nation’s population.) Upon his death in 1972, the Penrose Hypothesis was little more than a footnote to a brilliantly eclectic career.

Times have changed. In recent decades, studying the relationship between prisons and asylums has become something of a cottage industry for social scientists interested in the impact of “deinstitutionalization,” a term commonly applied to the widespread closing of state mental hospitals. It’s no secret that the number of institutionalized psychiatric patients in the United States has dropped precipitously in the past fifty years, while the nation’s prison population has exploded. At first glance, mass incarceration appears to have filled the void created by the virtual abandonment of our asylums—the Penrose Hypothesis writ large. A mentally ill American today is “far more likely to be treated in jail or prison,” a Stanford Law School study concluded, “than in any healthcare facility.”

The cruel irony is that America’s asylums were created, in large part, to separate the insane from the criminals and prostitutes who constituted the “unworthy poor.” There is no better example of this than nineteenth-century New York City, where large sums were expended to build a cluster of distinct institutions on a deserted spit of land known as Blackwell’s (now Roosevelt) Island. Opened in 1839, Blackwell’s would eventually house multiple asylums, prisons, workhouses, and hospitals. By law, “lunatics” in New York could no longer be confined with “any person charged with, or convicted of, any criminal offense.”

The new asylums, purposely designed to “be as little like the Penitentiary as possible,” contained tidy single rooms with few physical restraints. Blackwell’s seemed a reformer’s paradise—a place of justice and healing, where idleness was forbidden and the word, and fear, of God prevailed. “Even the marginalized and maligned would have it better here,” writes Stacy Horn in Damnation Island, a searing account of good intentions gone awry. “What could be more restorative…than the peaceful, verdant island in the East River, tucked safely away from vice and crime?”

It didn’t turn out that way. The vast numbers of “poor, sick, mad and criminal” dashed any hopes for serious reform. And the ballooning costs of warehousing them—increasingly immigrants from famine-ravaged Ireland—created fierce resentments across class and ethnic lines. Horn believes that the experiment was fatally flawed by the decision to place all services on Blackwell’s in the hands of political hacks who knew little about penology and mental illness but quite a lot about nepotism and patronage. Corruption, overcrowding, malnutrition, beatings, suicides, disease—all took a grisly toll. Among the few early visitors to Blackwell’s was Charles Dickens, on a grand tour of America’s public institutions. He could hardly wait to leave. “I never felt such deep disgust and measureless contempt,” Dickens wrote, “as when I crossed the threshold of this madhouse.”

To save money, unsupervised convicts were assigned nursing and maintenance duties in the asylums, mixing freely with the inmates and spending nights locked up with them. Physical abuse and chemical restraints, especially morphine and opium, became commonplace. Before long, Horn contends, the terms “criminal” and “insane” were close to interchangeable on Blackwell’s, a “devastating association” that made the mentally ill appear more dangerous than they were.

For years, Blackwell’s geographic isolation kept it safe from prying eyes. That luxury ended in 1887, with the publication of Nellie Bly’s sensational exposé in Joseph Pulitzer’s New York World. Having bought the dying newspaper from the robber baron financier Jay Gould, Pulitzer had revived it with lurid stories, vivid graphics, and banner headlines—“FRENCH SCIENTIST AND EXPLORER DISCOVERS A RACE OF SAVAGES WITH WELL-DEVELOPED TAILS” being a prime example. Pulitzer fancied himself a muckraker, uncovering graft and brutality in municipal institutions. Bly’s assignment was to get herself inside Blackwell’s main asylum—a task she prepared for by spending several hours in front of a mirror “practicing to be a lunatic.” In short order she was arrested, carted off to police court, sent to Bellevue Hospital for observation, declared insane, and shipped to the island.


Her exposé, Ten Days in a Mad-House, spared few gory details. Conditions inside the asylum, she wrote, were vile enough to turn anybody insane. The City Council investigated, promised greater oversight, and budgeted additional funds for the inept Department of Public Charities and Correction. It was good theater, but little more. By the 1890s, Blackwell’s enormous institutions housed close to 16,000 inmates, or 1.2 percent of the city’s entire population. Their sheer size mocked the reforming spirit that had created them.

Horn ends her story as the twentieth century begins. “They didn’t get it right,” she concludes, noting that the most potentially significant change—the splitting of Public Charities and Correction into two separate departments in 1895—had little effect. It’s hard to disagree. Though the institutions on Blackwell’s would be shuttered in the coming years, the ones that replaced them—like the violent, overcrowded, and “nearly unlivable” city jail on Rikers Island—were hardly better. Horn offers no solutions; she is a storyteller, and a good one. The problem is that her often riveting account rarely connects Blackwell’s to the outside world. There is little about the waves of immigration that transformed New York City, or the professionalization of its police force, or the advances in medicine and public health during a century of revolutionary change. As such, we never quite get off the island.

How did one become insane? This question grew more complicated as asylums spread across Europe and the United States, and detailed recordkeeping became the norm. By the early 1700s, officers at London’s Bethlem Royal Hospital—better known as “Bedlam”—claimed that “by God’s Blessing…there have been above two Patients in three cured,” a wishful boast, to be sure. Bethlem’s patient registers listed numerous causes of insanity, including “Misfortunes,” “Family and hereditary,” “Frights,” “Love,” “Drink,” “Pride,” “Parturition,” “Fever,” and “Venereal” disease. As the UCLA historian Theodore Porter makes clear in Genetics in the Madhouse, an exhaustive and thoroughly original study of human heredity research, the use and misuse of asylum statistics have quite a checkered past.

By the middle of the nineteenth century, Porter writes, state mental hospitals had become even more important than prisons and poorhouses. For one thing, they served a vital purpose by relieving families of their most burdensome members. For another, they claimed better results. Recordkeeping at these institutions showed unusually high success rates. In one notable example, the Bloomingdale Asylum in New York City discharged the same female patient forty-six times as “recovered.”

This flimflam had its limits. The public couldn’t help but notice that many of the asylum patients returning to society hadn’t been “cured,” and that the numbers of those entering and reentering these institutions were alarmingly high—as was the cost of running them. According to Porter, growing public anxiety moved asylum doctors to focus on heredity as the primary cause of mental illness. There was nothing new to this; heredity had long been connected to insanity. What had changed was the greater emphasis it received—a shift caused less by the spread of Darwinism, Porter believes, than by the need of “alienists” (the former term for psychiatrists) to explain the limits of asylum care.

Data collection now became more crucial, though the purpose had changed. The vast records of the asylums would be used to construct intricate family trees that traced feeblemindedness and insanity across generations. Even better, these data meshed nicely with the rise in the early 1900s of Mendelian genetics, which provided an air of scientific legitimacy. Asylums and prisons weren’t to blame for failing to cure mental illness and criminal behavior; genes were.

A new movement arose—a pseudoscience called eugenics—that aimed to cull the herd by keeping those with “undesirable” traits from reproducing. Porter is careful to differentiate the many alienists, biologists, and social scientists who appeared to embrace it. Lionel Penrose, for example, held a professorship in eugenics at University College London but looked upon the sterilization of the “unfit” as senseless and barbaric. He would later change his title to Professor of Human Genetics, noting that “only a lunatic would advocate such a procedure to prevent the occurrence of a handful of harmless imbeciles.”

But others—and there were many—did indeed employ the data of the asylums to devastating effect. Tens of thousands of prisoners and asylum inmates would be sterilized in the United States, with the full approval of the nation’s highest court. What began in America as statistical cover for elitist bigotry, Porter concludes, would wind up providing the bedrock for Nazi science, “moving beyond incarceration and sterilization to mass murder.”


Eugenics, it appeared, was no aberration. Modern asylum care in America became something of a magnet for controversy. One decade would see the rise of lobotomies, the next would bring primitive insulin shock. By the 1960s, public support for the nation’s mental hospitals had all but collapsed under the weight of multiple exposés, with psychiatry itself under siege.

The demise of America’s asylums is examined in two superb accounts by Ron Powers, a Pulitzer Prize–winning journalist, and Alisa Roth, a frequent contributor to National Public Radio. Powers’s title comes from a flip (if not entirely untrue) remark by a member of Wisconsin governor Scott Walker’s staff: “No one cares about crazy people.” The book—part memoir, part history—is deeply personal. Both of Powers’s children, Kevin and Dean, were diagnosed with schizophrenia, and both attempted suicide; Kevin succeeded. Powers believes that Kevin and Dean were victimized, in part, by a system that protects the “rights” of the mentally ill from “involuntary treatment”—requiring a hospital, for example, to obtain a court order before medicating a patient in distress. Such shortsightedness in dealing with those incapable of making rational decisions, he contends, is rooted in the same failed approach that depopulated our asylums.

A. Birrell/Private Collection/Bridgeman Images

Engraving of the figures ‘Melancholy’ and ‘Raving Madness’ over the gateway of Bethlem Hospital, known as ‘Bedlam,’ London, 1805

When the 1960s began, more than 500,000 people were confined in these institutions. Though conditions varied, the popular perception, fueled by movies and novels, was of medieval snake pits run by heartless bureaucrats and sadistic attendants. Thus when President Kennedy signed the Community Mental Health Act of 1963, almost everyone, including the medical establishment, applauded. The plan was to move these patients back into their neighborhoods, close to loved ones, where, as Powers puts it, “a sunlit archipelago [of] fifteen hundred small, freshly constructed ‘community health centers’” awaited.

It was a time for celebration, not hard questions. Federal money would be channeled through the states and municipalities, which were responsible for creating the centers. Would they follow through? Would the mentally ill be welcomed back into their communities? Would they receive better psychiatric care in a decentralized environment? Would federal funding ebb and flow with the spending habits of the political party in power?

Much depended on the magic of pharmaceuticals. New drugs like Thorazine had been approved to treat schizophrenia and other psychotic disorders. Thorazine wasn’t a cure; it simply controlled the symptoms. And to be effective it had to be taken regularly, despite troubling side effects. Heavily marketed as the psychiatric equivalent of miracle vaccines and antibiotics, Thorazine almost certainly made doctors and politicians more comfortable in choosing community care over institutionalization. As Powers writes, with a whiff of hyperbole, “After 1955…almost literally everyone believed that Thorazine and its progeny could do the job. No muss, no fuss.” Deinstitutionalization, he speculates, “might never have taken place had Thorazine not been misperceived as a cure.”

Powers provides a scathing critique of the forces that waged war against traditional psychiatry in the 1960s, undermining the protections, however restrictive, that kept distressed patients from harming themselves. Heading that list was Dr. Thomas Szasz, a Hungarian-Jewish refugee whose fear of state power had been shaped by Hitler and Stalin. Calling mental illness a myth created by a coercive profession, he compared involuntary hospitalization—indeed, any form of enforced treatment—to slavery. His “antipsychiatry” books sold briskly, appealing to a counterculture scornful of elites. “If you talk to God, you are praying,” he wrote. “If God talks to you, you are a schizophrenic.”

Szasz was hardly alone. The 1960s produced an alternative vision of mental illness, led by R.D. Laing, Michel Foucault, Erving Goffman, and Ken Kesey, among others, in which the patients appeared saner than their keepers. Asylums weren’t only barbaric, they were unnecessary. Joining the chorus were civil liberties groups, asylum survivors, budget-conscious conservatives, and legions of conspiracy theorists, including L. Ron Hubbard, the founder of Scientology, who helped Szasz organize the Citizens Commission on Human Rights to “liberate” patients from psychiatric oppression.

By 1980, deinstitutionalization was in full swing. The nation’s asylum population had dropped by more than 70 percent, to fewer than 140,000. (The best current estimate is 45,000 in a country that has doubled in population since the 1950s.) Meanwhile, the goals and promises of the Community Mental Health Act went largely unmet, as former inmates returned to localities unprepared, and often unwilling, to assist them. Homelessness rose dramatically, as did psychiatric visits to jam-packed emergency rooms. “Unfortunately,” says Powers, “‘the community’ came to mean ‘the streets.’”

Alisa Roth’s Insane approaches deinstitutionalization from a different angle—the criminalization of mental illness. It takes the reader into the closed world of state prisons and city jails, where psychiatric treatment, loosely defined, is court-mandated and perfunctorily performed. Roth is wary of applying the Penrose Hypothesis to the current crisis. It’s clear, she writes, that America’s incarcerated population grew dramatically in the latter part of the twentieth century—from 200,000 to more than 1.4 million. But it’s equally clear, she notes, that the people once housed in state asylums bear little resemblance to the people now locked up in prisons. Using data from a recent study, Roth shows that the typical patient in a state asylum in the 1950s was “elderly, female, and white.” Today, by contrast, the typical prison inmate is “young, male, and not white.” The study estimates that depopulating the asylums “accounted for only between 4 percent and 7 percent of the overall rise in incarceration.” As Roth concludes,

it’s not that one caused the other. Rather, both problems have been fundamentally shaped by many of the same forces: lack of resources, lack of effective political interest, and, above all, a lack of understanding of the actual needs of those who are sick.

It’s widely claimed (though frequently challenged) that one in two prisoners has some form of mental illness, with a smaller, though substantial, percentage suffering from schizophrenia and bipolar disorder. Most are young blacks and Hispanics swept up by the policies that drive mass incarceration: the war on drugs; broken windows policing, which targets minor offenses; and mandatory minimum sentencing. Like Powers, Roth stresses America’s failure to provide the vital community mental health services first promised in the Kennedy years. In shifting that task to our prisons, she notes, we’ve overtaxed the institution least qualified to handle it—one specifically designed to punish and to discipline.

If there is one truism regarding mental illness, it’s that the earlier and more consistent the treatment, the better the patient does. Those who reach prison rarely fit this mold. Incarceration is often their first encounter with professional care. This means that our prisons consistently receive “the sickest of the sick,” says Roth, “those who most urgently need intensive treatment.”

Insane chronicles the teeming, poorly staffed psychiatric wards, where inmates can go for weeks without seeing a clinician and “therapy sessions—when they happen—last only a few minutes.” Solitary confinement, widely acknowledged to aggravate mental disorders, is still employed as a disciplinary measure, while suicide remains the leading cause of death, despite precautions like hard-mesh “turtle suits” that “can’t be torn or tied into a noose.” Today the most common treatment for the incarcerated is simply to medicate them and hope for the best. In California, close to 20 percent of state prisoners are taking psychotropic drugs. It is, after all, the quickest, cheapest way to control large numbers of patients.

Some of the most revealing sections of Insane deal with the officers who patrol these wards. Largely ignored until a Nellie Bly–like scandal erupts, they face conditions most of us can barely imagine. Many inmates “are either openly aggressive—growling, snarling, yelling, banging on doors—or completely unresponsive.” Sanitation is a nightmare; the odors in these wards range from revolting to unbearable. Scatolia—the term for playing with feces—is endemic in the wards, with those who hurl their bodily wastes at staffers known as “gassers.” The correction officers’ union at Rikers Island keeps a running tally of members “splashed w/possible blood-urine-feces.” An officer at the LA County jail, which houses one of the nation’s largest and better-run psychiatric units, says he never feels prepared for what’s about to happen: “One day I get shit thrown on me or get spit on…and then the next day, it’s ‘Hey, how’re you doing?’”

Roth well knows the patience and thick skin this work requires. “The deputies I observed…treated the prisoners with kindness and care,” she writes of the LA Mental Health Unit, adding that it was possible, “likely even, that my presence meant they were on exemplary behavior.” Burnout is inevitable; the very precautions of the job create a mindset in which inmates become “something other than human, creatures to be feared.”

Making matters worse, Roth believes, are the federal privacy (or HIPAA) rules that prevent the clinicians from revealing a prisoner’s diagnosis. Put simply, essential details that might help these deputies better understand a person’s behavior are unavailable to them. This isn’t the outside world, says Roth, where patient confidentiality might save a patient’s job, or insurance, or reputation. This is a place where officers rely on their instincts and experience, where accurate information is essential, and where privacy rules, however well intentioned, “seem ridiculous, if not downright dangerous.”

Like Powers, Roth is open, albeit reluctantly, to the idea of reopening America’s asylums—but only as a backup to aggressive community care involving qualified personnel, structured therapy, and the monitoring of scheduled appointments. The people who might benefit from these old-fashioned institutions today are relatively few—nothing like the 550,000 patients of the past. They’re the ones with treatment-resistant disorders so severe that long-term hospitalization may be the best answer—better, certainly, than homelessness or incarceration.

Resistance has been fierce. Asylums have a history to confront and an image to overcome; the ghost of Nurse Ratched won’t easily be cast aside. They remain perfect vehicles for patient abuse, critics charge, because they are isolated and coercive, and because their culture fosters helplessness and dependency. Why would they be any better in the twenty-first century than they were in the past?

Both sides, however, would surely agree that jails and prisons are the wrong places to deal with mental illness. We can approach this problem from one of three directions: by accepting that jails and prisons will remain the leading providers of treatment for the mentally ill and giving them the resources to do better; by limiting the mass incarceration of mentally ill people and handling them outside the criminal justice system; or by allowing the current patchwork of prison care to drag on indefinitely, without fundamental change. The choice today is complicated by a political current in which social programs are being gutted in the name of cost-cutting and privatization. For mental health advocates, however, history provides a sobering lesson from the not-too-distant past: much will depend on the ways in which they present their conflicting views. A return to the internecine warfare of the 1960s would be disastrous for all concerned.