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The Open Door. The Mental Health System Transformed

In twenty-first-century America, about one in every three homeless people suffers from severe mental illness. The rise of homelessness among those suffering from severe psychiatric disorders paralleled the decline of the state-funded mental institution and the creation of the system of mental health care that replaced it, a process that began slowly in the mid- 1950s, accelerated in the late 1970s, and continues to the present. In the period from 1955 to 1975, the resident population of state mental hospitals dropped by 66 percent (Bachrach, 1978). By 1998, the patient caseload of state mental institutions dropped 90 percent from the 1955 peak of over a half million patients (Lamb & Bachrach, 2001).


For nearly one hundred years, from the mid-nineteenth century to the end of World War II, public mental health care for people with severe mental illness took place in state funded and operated mental hospitals (Caplan & Caplan, 1969; Rothman, 1971). Often located far from population centers, these institutions provided all of an individual’s treatment and support needs. Publicly funded care was available to all who needed it, regardless of their ability to pay or the length of their stay in the hospital (Grob, 1991). By the twentieth century, mental hospital caseloads consisted mostly of people with chronic conditions, sometimes associated with aging or underlying somatic disorders (Grob, 1991). Many hospital admissions occurred through a process of compulsory commitment (Duke Law Journal, 1969). Treatment options were limited, and custodial care predominated. Patients lacked the opportunity to play an active role in their care and treatment, typically accepting whatever treatment was recommended. It was not uncommon for the more disabled individuals to live out their lives under asylum care.

During the 1930s and early 1940s, the focus on the Great Depression and World War II upstaged concern for the aging and deteriorating physical plants and chronic staff shortages of state mental hospitals. Despite these problems and efforts to reduce hospital stays (Goldman & Morrissey, 1985), the growth in the population of state mental hospitals continued to accelerate (Grob, 1991). As hospital staff members were drawn into the war effort, the shortage of trained and qualified personnel grew more acute.

It was during this time that reports of the abuse and neglect of patients and the deplorable conditions in mental asylums surfaced in the lay press. Publications in the popular press, such as Albert Q. Maisel’s “Bedlam 1946” article in Life magazine, Mary Jane Ward’s novel The Snake Pit, and Albert Deutsch’s “The Shame of the States” exposed to the general public the conditions of state mental asylum care (Grob, 1991). Torrey (2014) notes how negative appraisals of mental asylums were also apparent within the mental health professions; and Rochefort (1984) details how scientific studies of the mental hospital (Belknap, 1956; Caudill, 1958; Goffman, 1961; Stanton & Schwartz, 1954) reinforced the conclusion that “mental hospitals were making worse the very problems they were intended to remedy.”

In the early years following the end of World War II, the mounting criticism of state mental institutions in governmental, medical, and lay circles created a context for change. In the second half of the twentieth century, mental health care in the United States evolved in response to advances within the psychiatric professions, a more prominent role of the federal government in mental health policy, funding, and entitlement reform, and the expansion of civil liberties for the mentally disabled.

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