For much of human history, people with mental illness were thought to be possessed by gods or devils. Madness, as it was called, was believed to be supernatural, not natural. Some Greeks, including Plato, viewed mental illness as a kind of spiritual gift, a portal into new ways of seeing. Many believed that madness revealed hidden intuitive and mystical knowledge.¹ The idea that mental illness was in fact a way toward wisdom could still be found in medieval Christian visionaries.²

This may have been how people viewed 13th-century Catholic Saint Francis of Assisi, after whom San Francisco is named. Francis is known for renouncing his family’s wealth and caring for lepers. But he also preached to birds and animals in a state we might today call psychotic, and suffered from what some scholars believe was mental illness.³ When his parents intervened, possibly by trying to appoint a legal guardian to manage Francis’s finances, the local bishop ruled that Francis could have his freedom as an “ecclesiastical person” if he renounced his family and inheritance.⁴

Over time, people came to see madness as a physical illness that interfered with rational thinking and not as a divine blessing or demonic curse.⁵ In ancient Greece the physician Hippocrates proposed a naturalistic explanation, and biologically based medicine returned to Europe from the Arab world during the Middle Ages.⁶ This view gave rise to mental hospitals and asylums to treat the mentally ill. The English started the first one, Bethlehem Hospital, near London in 1247, or “Bedlam” for short.⁷ It was a grim place. “On the second floor is a corridor and cells like those on the first floor,” noted a visitor, “and this is the part reserved for dangerous maniacs, most of them being chained and terrible to behold.”⁸

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In the early 18th century, some in Britain condemned madhouses as infringing on rights.⁹ The English writer and journalist Daniel Defoe, famous for his novel Robinson Crusoe, wrote a pamphlet denouncing the upper-class men who used mental institutions as a way to be rid of their sane wives so that they could more easily indulge in infidelity. Defoe argued that the institutions themselves made women of sound mind fall into madness.¹⁰

In 1818 the French monarchy hired a researcher to investigate the conditions under which the mentally ill were kept. His report shocked the nation. He described patients kept in tiny, infested, and dark cells where they were barely clothed and had only straw to insulate them from their cold and damp surroundings. The madhouses were so wretched, he concluded, that the French monarchy would not subject their prized wild beasts to the same conditions.¹¹

It was a similar story in the rest of Europe. In 18th-century Ireland, mentally ill family members were locked in holes five feet beneath their cottage floors, a space too small for most to stand. In Germany, one teenager with mental illness was shackled in a pigpen for so long that he lost the use of his legs; in England, the mentally ill were chained to the floors of workhouses; and in one Swiss city, one-fifth of the mentally ill were restrained constantly.¹²

Mental health found its first great American reformer in Dorothea Dix, who had encountered the nascent mental health reform movement during a visit to Great Britain. Dix crusaded to pull the seriously mentally ill out of abusive and degrading conditions in jails, homes, and poorhouses, and put them in hospitals. She pushed for hospitals to phase out brutal practices like physically restraining patients. Ultimately, her work led to 32 asylums being opened. An 1880 survey found that about the same number of mentally ill were living at home (41,083) as lived in hospitals (40,942) while 9,302 were in almshouses, charitable housing that sometimes included basic care services. Only 397 were in jail, making the mentally ill just 0.7 percent of the total jail population.¹³

Dix’s humanism was felt in California. San Francisco’s Marine Hospital opened in 1850 to care for sick sailors and the mentally ill.¹⁴ Previously, a ship called the Euphemia had served as a makeshift mental hospital and jail, where individuals determined to be “insane” were shuttered in the hold alongside criminals deemed too dangerous to hold on land. Conditions were cramped, with six to eight men crowded into tiny cells.¹⁵ In response, the California legislature one year later established three general hospitals, including the Sacramento State Hospital, which served as a general hospital as well as for the treatment of the mentally ill.

In 1853, the Insane Asylum of California became the first publicly funded mental health facility west of the Missouri River. The resident physician required his attendants to refrain from violence or flashes of anger when caring for patients. He encouraged a sense of self-respect.¹⁶ In 1875, California opened Napa State Asylum, where inmates raised poultry, vegetables, dairy cows, orchards, and other crops.¹⁷

But over time, state mental hospitals abused their power to involuntarily hospitalize people and grew overcrowded. People were committed for reasons including “excessive masturbation,” being “kicked in the head by a mule,” and “habitual consumption of peppermint candy.”¹⁸ Women who defied social mores were diagnosed with “hysteria.”¹⁹ In the 1940s a visitor to one hospital described 250 naked men simply milling about in a large room. “Patients squatted on the damp floor or perched on the window seats. Some of them huddled together in corners like wild animals.”²⁰

Life magazine in 1946 published an exposé of state mental hospitals. “Hundreds are confined in ‘lodges’—bare, bed-less rooms reeking with filth and feces—by day lit only through half-inch holes in steel-plated windows, by night merely black tombs in which the cries of the insane echo unheard from the peeling plaster of the walls.”²¹

In response, Congress in 1946 passed, and President Harry Truman signed, the National Mental Health Act, which created the National Institute of Mental Health (NIMH). Congress’s intention was for NIMH to focus on “diseases of the nervous system which affect mental health.”²²

But reformers increasingly believed that addressing mental health required much broader societal changes. Many reform leaders viewed mental illnesses like schizophrenia and bipolar disorder as the result of class, racial, and other forms of inequality and oppression, and not the result of biology.²³ Political action was thus necessary to create “mentally healthy” environments, organize tenants, and fight landlords. “The changes I am talking about,” said a leader at the new National Institute of Mental Health, “involves a redistribution of wealth and resources.”²⁴

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The big idea was to replace public mental hospitals with 1,500 privately owned, community-based mental health centers. But fewer than half were ever built.²⁵ Part of the problem was that the leaders of community mental health clinics were unable to impose involuntary care. It is thus partly understandable why they tended to serve the easiest-to-treat.

It is true that Kennedy had envisioned better funded community health centers, and that, over the years, various administrations cut the budgets for this program. But the centers also abused their mandate, sometimes building tennis courts, swimming pools, and rooms for fads like “inhalation therapy” that did nothing to help the people who most needed care.²⁶ “The people who run the mental health industry are not bad people,” emphasized one advocate. “But their goal is no longer to help those with serious mental illness.”²⁷

The tragic irony is that many of the people who had drawn attention to the poor conditions in mental hospitals had hoped to mobilize the public to increase funding for better care in them, not shut them down entirely.²⁸ The hospitals had been underfunded because of the Great Depression, and understaffed because of World War II. The population of state mental hospitals had increased from 150,151 to 423,445 between 1903 and 1940. Meanwhile, around half of the hospitals’ professional staff worked on the war effort.²⁹

Idealism and ideology had triumphed over pragmatism and reason. Between 1948 and 1962, the mental health center that reformers had pointed to as the model had not prevented a single case of mental illness or even treated a single individual with schizophrenia or other major psychiatric disorder.³⁰ As a result, notes a historian, “The majority of lives were little different than they had had while hospitalized ... and a significant number were considerably worse off.”³¹

Some mental health reformers regretted what they had done. “The deformed creature that has developed from the original community mental health center movement,” said one of them, “does not arouse much enthusiasm in any of us who had some more grandiose visions.”³²

In 1961, the French historian Michel Foucault published a book, Le folie et la raison, which was translated into English in 1965 as Madness and Civilization. The book made Foucault one of the most famous intellectuals in the world, and enormously popular in California, where he taught as a guest lecturer during the mid-1970s. Foucault’s book had a major impact on how we treat, and don’t treat, the seriously mentally ill.

Foucault argued that the supposedly humanistic treatment of the mad as suffering from mental illness was, in fact, a more insidious form of social control. Before 1500, the mad wandered freely in Europe, Foucault argued. After 1500, Europeans began to medicalize madness, treat it like an illness, as a way not just to control the mad but also to establish what was rational, normal, and healthy for the rest of society. Mental hospitals emerged at a time, Foucault argued, when the state was seeking to impose rational order on societies. And that started with policing the boundary between sane and insane.³³ Foucault even criticized a humanistic asylum in England whose pioneering psychiatrist no longer used physical restraints, which the mentally ill today testify are terrifying and even constitute a kind of torture, on his patients. Said the psychiatrist, “these madmen are so intractable only because they have been deprived of air and freedom.”³⁴

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Foucault wasn’t alone in his attack on psychiatry and mental hospitals. In 1961, an American sociologist, Erving Goffman, published an influential book, Asylums: Essays on the Condition of the Social Situation of Mental Patients and Other Inmates, which compared mental hospitals to concentration camps. That same year, a psychiatrist named Thomas Szasz published The Myth of Mental Illness, which argued that psychiatrists and others invented the concept of mental illness, with no biological evidence, in order to punish people who were different from the norm.

The anti-psychiatry movement became a cultural phenomenon in 1962 with the publication of Ken Kesey’s best-selling novel, One Flew Over the Cuckoo’s Nest. It revolves around a socially deviant but nonetheless sane man who feigns mental illness so he can go to a mental hospital rather than prison. He is drugged, electro-shocked, and eventually lobotomized. The novel was adapted as a Broadway play and an Oscar-winning 1975 film starring Jack Nicholson.

Szasz formed an alliance with the ACLU, which began to crusade politically, and litigate through the courts, for an end to involuntary treatment of the mentally ill.³⁵ Because psychiatrists were no more reliable at diagnosing mental illness than flipping coins, argued the ACLU’s most influential attorney on the matter in 1972, they “should not be permitted to testify as expert witnesses.”³⁶ Said another leading civil rights attorney in 1974, “They [the patients] are better off outside the hospital with no care than they are inside with no care. The hospitals are what really do damage to people.”³⁷

In early 1973 the journal Science published an article, “On Being Sane in Insane Places,” by a Stanford sociologist, David Rosenhan, who claimed to have sent research assistants into several mental hospitals where they were misdiagnosed with mental illness. “We now know that we cannot distinguish insanity from sanity,” he concluded.³⁸ The study received widespread publicity and “essentially eviscerated any vestige of legitimacy to psychiatric diagnosis,” said the chairman of Columbia’s Department of Psychiatry.³⁹ “Psychiatrists looked like unreliable and antiquated quacks unfit to join in the research revolution,” wrote another psychiatrist.⁴⁰

Rosenhan’s study became one of the most read and reprinted articles in the history of psychiatry, but a journalist in 2019 published a book describing so many discrepancies that she questioned whether it had ever even occurred. She only found one person who said he had participated in the study, and he said he was treated well by the hospital and had been discharged simply because he asked to leave.⁴¹

The psychiatric hospitals disappeared, but the anti-psychiatry stigma remained. “I experience stigma every day as a psychiatrist,” said one in 2016. “The profession to which I’ve dedicated my life is the most denigrated and distrusted of all medical specialties. There’s no anti-cardiology movement that’s trying to stamp out cardiology. And there’s no anti-oncology movement that’s trying to ban cancer treatment. But there’s a very violent anti-psychiatry movement that claims there’s no such thing as mental illness and wants to eliminate psychiatry.”⁴²

That same year, when the chief medical officer of the federal Substance Abuse and Mental Health Services Administration under the Department of Health and Human Services quit her post, she criticized the anti-psychiatry movement. “Unfortunately, SAMHSA does not address the treatment needs of the most vulnerable in our society,” she said. “There is a perceptible hostility toward psychiatric medicine; a resistance to addressing the treatment needs of those with serious mental illness; and a questioning by some at SAMHSA as to whether mental disorders even exist.”⁴³

Liberals and progressives had gone, thanks in part to the ACLU, Foucault, and One Flew Over the Cuckoo’s Nest, from advocating humanistic psychiatric care to opposing it. Part of the reason progressives demand proof of mental illness in the form of violent assault, murder, or suicide is that they have lost faith in our capacity to recognize it and at times even denied its existence.

Excerpted from San Fransicko: Why Progressives Ruin Cities by Michael Shellenberger, published by Harper, an imprint of Harper Collins Publishers. Copyright © 2021 by Michael Shellenberger.

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