The Rise and Fall of the Asylum: Good Intentions, Hard Realities
Psychiatric asylums once stood as monuments of hope. They represented a humane vision that individuals with severe mental illness deserved care, protection, and sanctuary rather than neglect or incarceration. Over time, however, the asylum system declined—and many of its closures came with tragic unintended consequences.
The Asylum Era and Early Reforms
In the early 19th and 20th centuries, asylums (or state psychiatric hospitals) were built across the United States. Reformers such as Dorothea Dix advocated for public institutions to care for the “indigent insane” rather than leaving them in prisons or almshouses. Buildings were often constructed in the Kirkbride style, designed to bring sunlight, ventilation, and calm structure to patients’ lives.
These institutions offered long-term housing, treatment, structured activities, and safety. Their intent was to remove individuals from unsafe or neglectful conditions and provide continuity of care in a controlled environment.
The Rise of Deinstitutionalization
By the mid-20th century, the asylum system was under heavy criticism. Many institutions had grown overcrowded, underfunded, and rife with abuse or neglect. Public awareness and civil rights momentum demanded change. The introduction of antipsychotic medications (starting in the 1950s) offered a pharmacologic tool to manage psychosis and seemed to promise that patients could live outside locked institutions.
The passage of the Community Mental Health Act of 1963 marked a structural shift toward deinstitutionalization. The idea was that patients would be transitioned into outpatient care, smaller local clinics, group homes, and community-based resources instead of long-term institutionalization.
The logic was sound: more humane, less isolating, cost-sparing, and enabling patients to live integrated in society rather than behind locked walls.
The Fallout: Readmissions, Prisons, and Homelessness
Unfortunately, the vision of community care was never fully delivered. While many large psychiatric hospitals closed or drastically reduced their capacity, the outpatient infrastructure, housing support, social services, and enforcement of care obligations never scaled appropriately.
A result has been “transinstitutionalization.” Instead of being cared for in hospitals, many patients with severe mental illness have ended up in nursing homes, prisons, jails, homeless encampments, or repeatedly admitted to general hospitals. Data suggest that perhaps 16 percent of prison and jail populations suffer serious mental illness.
Some states saw dramatic rises in homelessness and criminal justice involvement among those with untreated psychiatric illness. In California, for example, following large-scale bed closures, many former patients found themselves without support, and many ultimately entered jails or emergency services. In the first year after California’s Lanterman-Petris-Short Act (which limited involuntary commitments), some local hospitals reported doubling of psychiatric admissions.
Studies show that reductions in psychiatric bed supply correlate with increases in suicide rates, especially where community mental health funding is inadequate to absorb the displaced population.
The Modern Tension: Acute Discharges vs. Long-Term Needs
Even today, I see the tension between short-term care pressures and long-term patient needs. Hospitals, constrained by insurance reimbursement and bed turnover goals, often push for rapid discharge even when a patient’s stability outside is fragile. Without robust community supports, these individuals may too soon relapse, cycle through hospital readmissions, or end up in jail again.
I believe there remains a segment of the population who truly do not function well in unstructured community settings. They may require extended care in specialized settings—modern equivalents of asylums but with safeguards, dignity, and therapeutic ambition.
Patients who cycle through short stays, then relapse, often present to me far sicker than before. Ideally, a system would allow transition from acute inpatient care to longer-term residential or state hospital settings until they regain stability.
But in many states, waitlists for civil commitment and state psychiatric facilities are long, and legal and financial hurdles make access slow. Even with this renewed executive interest in improving institutional capacity, there is no quick fix without massive expansion of beds and funding.
Trump’s 2025 Executive Order: “Ending Crime and Disorder on America’s Streets”
In July 2025, President Trump signed an executive order titled “Ending Crime and Disorder on America’s Streets” which explicitly references shifting homeless individuals into long-term institutional settings through civil commitment, particularly those suffering from serious mental illness or addiction. Critics warn that the order prioritizes involuntary treatment, restricts funding for “housing first” strategies, and may increase the risk of civil rights violations.
Supporters argue that enforcing civil commitment of those who cannot care for themselves will restore public order and safety. But unless the policy is paired with large-scale expansion of state psychiatric beds, community supports, and protections against overreach, the danger is that we repeat mistakes of the past.
The order also seeks to withdraw federal support for programs that do not enforce mandatory treatment conditions and shift grants toward cities that adopt stricter rules on public camping, loitering, or substance use.
Balancing Liberty and Care
It is vital to emphasize: civil commitment is never intended to be punitive. The goal each day must be to deliver high-quality therapeutic care, not to punish. Whether the objective is restoration so that the patient can return to community life or transition into an appropriate group home, institutional settings must always be respectful, safe, and rights-oriented.
We do not want a return to mass warehousing or indefinite compulsion without oversight. But in a system that lacks capacity and support, many vulnerable people suffer.
A Vision Forward
We must recognize that the psychiatric asylum system was not perfect, but its dismantling without adequate replacement infrastructure led to major fallout.
Any move to re-expand long-term psychiatric capacity needs to come with adequate funding, oversight, staff training, and legal protections.
Recommitment to truly supported outpatient care, housing-first models, community mental health centers, assertive community treatment, and supported housing must accompany any policy shift toward institutional care.
Policymakers must treat mental illness, homelessness, and public safety as intertwined public health challenges—not simply matters of law enforcement.
If Donald Trump’s executive order is to avoid repeating historical failures, it must be paired with real investment in beds, incentives for states to expand capacity, accountability in how civil commitment is applied, and unwavering commitment to restoring patient dignity and autonomy when possible.
We can neither gloss over the mistakes of the asylum era nor assume that we can return to them without better foundations. The path forward must be one that integrates care, rights, and structure—not just retreat behind locked doors.
