It Wasn't the Asylums
The most common explanation for the people on our streets is that we emptied the state hospitals and turned the mentally ill out into the cold. We did empty the hospitals. But they stood largely empty for a decade before mass homelessness arrived, and that gap is the whole story.
It's one of those explanations that feel settled, the kind even careful people repeat. Decades ago, as it's usually told, we tore down the asylums and pushed out the patients who had nowhere else to go, and that's why there are people talking to themselves on our sidewalks today. It is a tidy story, and parts of it are true.
We emptied the hospitals, often coldly, and most of the community care promised to replace them was never built. So this isn't an argument that nothing happened, or that the people discharged were treated well. They were not.
The emptying is real. The timing is the problem.
It happened here.
North Carolina eventually had four big state hospitals, each serving one region of the state. The one for our western counties is Broughton Hospital in Morganton, an hour east of Asheville. It opened in 1883 and expanded for decades until its campus could hold thousands. Walk it today and you'll find a few hundred patients on grounds built for many times that number.
The same emptying happened across the country. In 1955, the nation's public mental hospitals held about 558,000 people. By 1975 that had fallen to roughly 200,000. The steepest drop came in the single decade between 1965 and 1975, a fall of nearly 60 percent. By 1980, the patient count was down about three-quarters from 1955.
New medicines made shorter stays possible. Courts narrowed who could be held against their will. States, eyeing the cost of the hospitals, were glad to discharge patients. The emptying was mostly over by the late 1970s.
Most of the fall in the patient count comes before the rise in homelessness
The hospitals emptied through the 1960s and 70s. Mass homelessness did not arrive until the 1980s.
The hospital figures are real counts. The homelessness line is a rough sketch of the documented trend, not a year-by-year count, because no national tally existed before the late 1980s.
The hospitals had largely emptied between 1955 and 1975. Mass homelessness, the kind we'd recognize now, first appeared as a national crisis in the early 1980s, but it didn't grab the country's attention until the mid-1980s.
If turning patients out of hospitals had put them directly on the sidewalk, the sidewalks would have filled in the 1960s and 70s, while the emptying was actually happening. They did not. So where did hundreds of thousands of discharged people go, in the years before homelessness became visible?
Most went home to family. Some went to boarding houses and nursing homes. And many went to the cheapest housing the country had: the single-room-occupancy hotels, the SROs. There, a poor person could rent a room by the week for a few dollars, no lease, no credit check. The care was thin and the rooms were often grim. But a room is not the street. For 20 years, that thin floor held.
Then three things happened close together, and the floor gave way.
Many of the cheap rooms that had quietly housed former patients were converted or torn down. The federal money committed to new subsidized housing, which might have replaced those rooms, was cut by about 80 percent. And a federal review of disability cases stripped benefits from hundreds of thousands of people, many of them with serious mental illness.
So the room vanished, new rent help shrank, and the small disability check that had paid for the room was canceled. Often all three happened within a few years of one another. That is when most people ended up on the street. Not when the hospital discharged them. When the housing that caught them was taken away.
Still, mental illness had something to do with it.
Emptying the hospitals created a large group of people with unusually little to fall back on: poor, sometimes needing specialized care, often without family nearby or the means to fight a brutal housing market. When the cheap rooms disappeared, these former patients were among the very first with nowhere to go.
So their illness helped decide who ended up outside. It did not decide how many. The number was determined by how much low-cost housing we destroyed and how little we replaced.
The asylums are the wrong suspect.
It's more comforting, in a way, to blame them. Blaming them turns homelessness into the lingering side effect of one old decision about the mentally ill: something finished, far away, and nobody's fault anymore. A mistake we cannot take back.
The truer story is harder, but more hopeful. We did not fail by letting people out of hospitals. We failed by losing the rooms they could afford and cutting the checks that paid for them. In much of the country, we're still failing that way now. A thing we are still doing is a thing we can choose to stop.
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