C (4:42)

Over 2,000 miles away in Milledgeville, Georgia, a little red trolley sits huffing and puffing on the side of the road. It's a blazing hot day and a group of sweaty tourists staggers out into the glare. Ahead, a grassy hill falls away toward the tree line. Rows of rusted markers poke out of the ground like jagged teeth.

B (5:02)

So what you see before you is the Cedar Lane Cemetery.

C (5:05)

The tour guide, Walter Reynolds, beckons everyone over.

B (5:08)

And these markers here, these were designed with two purposes in mind.

C (5:13)

The markers bear no inscriptions or names, just patient numbers. Stark reminders of more than 25,000 asylum inmates buried here on the grounds of Central State Hospital. Once the world's second largest mental institution. Only New York's Pilgrim State Hospital housed more patients.

B (5:31)

So it was not uncommon for people that were sent here by their families to basically have been forgotten about.

C (5:38)

People like Tillman Barnett, a 30 year old farmer locked up for quote, unquote, lunacy in 1842. His cause of insanity was unknown, but he died only six months later.

B (5:50)

Individuals that suffered from things like seizures, they might have been assumed to have been possessed by demons. Particularly in the more rural parts of

C (5:58)

Appalachia and Georgia, most patient names and records have been lost to time. Their stories live on only in hushed family whispers and faded photo albums. For others, even their own descendants have forgotten them. Thousands ended up here for any one of a laundry list of maladies, Many for things we now recognize as mental illness, depression, schizophrenia, bipolar disorder. Others found themselves climbing the hospital's stone steps because of physical handicaps, developmental disabilities, or conditions ranging from syphilis and tuberculosis to dementia and addiction. Some came simply because their families wanted to get rid of them. At its peak, the hospital housed over 12,000 people, more than the population of Milledgeville at the time. But today, many of the halls that echoed with patient voices stand empty, desolate, and abandoned. Walter Reynolds, the central state tour guide, is a jack of all trades. He's spent time in radio, launched a small business, served as a city alderman, and is running for Milledgeville mayor. Reynolds roots here go deep. Four generations of his family worked on central state hospital's campus.

B (7:15)

Both of my great grandfathers worked at the state hospital. One worked on the farming operation. The other worked at the steam plant. Both of my grandmothers were nurses there, and my parents met at the department of corrections out there at central state hospital.

C (7:29)

Reynolds himself grew up in the shadow of the hospital. His great grandmother's house stands just off campus.

B (7:35)

I mean, you could see the back of the Jones building from her front porch. And we didn't think anything of it. That's just, you know, that was mamu's house.

C (7:43)

Only later, after much of the hospital closed down, did Reynolds begin to dive into its history.

B (7:48)

This is a place that predates the civil war. This is a place that predates the industrial revolution, the automobile. This is a place that predates electrification.

C (7:59)

The first water system in the city was built for central state hospital. Later, it gained its own electric grid, gas system, police department, and fire department, Even its own postal code.

B (8:10)

It was really and truly a city unto itself, a city within a city.

C (8:14)

At its peak, the institution employed about 6,000 people in various roles. The hospital was a major employer, and it casts a long shadow in local memory, not just because of its size.

B (8:26)

You can ask folks over the age of about 50 or so, you know, first thing they think of when they hear milledgeville, they think, oh, you know, that's where my parents used to threaten to send me if I didn't act right. You know, if you don't straighten up, they're going to send you to milledgeville.

C (8:42)

Reynolds says it's an important piece of American history for another reason, too.

B (8:46)

It shows the complete timeline of mental health and mental treatment in this country.

C (8:56)

Georgia started work on central state hospital in the 1830s. At the time, the institution was called the state lunatic, idiot and epileptic asylum. Its doors opened in 1842.

B (9:08)

And that's when we have our first patient arrive, a gentleman by the name of Tillman from nearby Macon. He is here for a very short period of time, about six to eight weeks before he expires of maniacal exhaustion. Which is a very Victorian, a very clinical way of saying that this gentleman just crazied himself to death, for lack of a better term.

C (9:35)

Back then, the United States was in the middle of an asylum boom. Mental hospitals like Central State were popping up all over the country. And there was one revolutionary idea behind all that construction, a new way of thinking about people with mental illnesses.

D (9:51)

And the idea was conceptually they are brethren.

C (9:55)

That's number one, that's Robert Whitaker. He's a journalist and author of the book Mad in America.

D (10:00)

Two, we don't know what you know, we don't know the causes of this, but we think of them as they are. They are creatures of God. In other word, God made them. And so they have often a God given capacity to regain their sanity, to get regain their reason.

C (10:17)

The philosophy Whitaker just described became known as moral treatment. It originated in part with a group of Quakers in Northeast England. Moral treatment stood directly opposed to medical ideas of the time.

D (10:29)

If you go back to colonial days and the very earliest days of the psychiatric hospital, the idea was that the mad, by virtue of having lost their reason, had descended to a level of a subhuman level, like to a level of a beast.

C (10:42)

Doctors concluded their patients didn't feel pain like everyone else and needed to be shocked back to their senses so they

D (10:49)

were seen as impervious to heat and cold. So they could go run around stark naked during the weekends. You could pay a small fee to come see the crazy people. Just like animals in a zoo I'm talking about.

C (11:00)

In contrast, the Quakers built small community style asylums, places of refuge and sanctuary to be governed by the Golden Rule.

D (11:08)

They weren't medical institutions, they were more like humanitarian care institutions. They would garden, get good food, there'd be a glass of sherry in the afternoon.

C (11:18)

Moral treatment jumped the pond and asylums started springing up in cities like Philadelphia, Hartford and Boston. Those early moral treatment asylums were surprisingly successful, Whitaker says. For example, McLean Hospital in Massachusetts released nearly 60% of its 732 patients as recovered or improved in its early days.

D (11:40)

And if you look at the entry documents that describe their symptoms, these are people really out of their minds in the way we would think about. They're psychotic, they're not mildly ill. They are seriously disturbed. And yet a high percentage were able to get better with this form of humane care. And historians have gone back, and they basically say we've never had outcomes as good as that. During that time when moral therapy, as it was called, held sway in the

C (12:04)

United States, the moral treatment idea inspired a stubborn schoolteacher named Dorothea Dix. She took up the cause and crisscrossed the country, calling for more state funding. I proceed, gentlemen, briefly to call your attention to the present state of insane persons confined within this commonwealth in cages, closets, cellars, stalls, pens, chained, naked, beaten with rods, and lashed into obedience.

D (12:30)

And the United States responded with the first sort of big public works project in its history was to build asylums for the man.

C (12:37)

By 1890, every state in the Republic had one or more mental hospitals. But moral treatment wasn't the guide star of the asylum system for long.

D (12:47)

What happened to that form of care? Well, what happened to that form of care, oddly enough, was that it became too successful.

C (12:53)

Asylums were supposed to be small, maximum 250 people.

D (12:57)

But once they set these up, communities began putting all sorts of people into these asylums. People with neurological diseases. Alzheimer's, dementia, syphilis.

C (13:09)

Populations exploded. At central state hospital, for example, the patient body swelled to about 2/3 by the turn of the century.

D (13:18)

It quickly became populated with people who had all sorts of neurological injuries in all old age. And, of course, people stopped getting better. And so by the 1890s, it was seen as a failed form of care.

C (13:31)

Still, asylum populations continued to grow. By 1955, over half a million patients across the United States lived in state hospitals. Asylum administrators abandoned moral treatment. But the asylum era continued. And now mental hospitals were bursting at the seams, filled with suffering human beings dealing with a wide range of complex physical, mental, emotional, and spiritual needs. Overcrowding and understaffing quickly became the new status quo. The trans Allegheny Lunatic asylum looms just off the main avenue of Weston, West Virginia. It's a sprawling Greystone Manor once home to about 2,400 patients. A sweeping walkway leads up to its glowering facade, and a sluggish fountain splashes in the summer glare. The asylum first opened in 1864. Today, it's one of the few old hospitals still still open for public tours. Back in the 1850s, the town of Weston lobbied hard to have it built

E (14:39)

here, and they actually got the brass band out when the inspection team came. So that's how it ended up here. There's flat ground, which is kind of rare, as well as the Fact that it's rural area and still is, the population today is not much different than it was in 1860.

C (14:59)

That's Greg Hill. He's a seasoned tour guide who's worked here for the last 17 years. He grew up in Weston and knows just about everything there is to know about this place. Like so many institutions of its day, Hill says the Trans Allegheny Lunatic Asylum was founded on the bedrock of moral treatment. Staff couldn't even use restraints on patients in the early days. But over time, all of that changed.

E (15:24)

It went from carriage rides on Saturday night through town to keeping people insecure wards.

C (15:32)

Hill attributes that to one major factor. Overcrowding.

E (15:36)

I was here in 1967 on a high school tour. It was so crowded, it was uncomfortable to walk through. It was just scary as could be.

C (15:46)

Amy Lowther is another tour guide. A West Virginia native and former history teacher. Her mom toured here with a church group in the 60s.

F (15:53)

The one thing she remembers is walking in here, this smell, the overcrowding, and there are so many naked people.

C (16:00)

Lowther points out another reason for the asylum's decline. Lack of funding.

F (16:05)

Money always plays a big part in things like this. So there wasn't the money to have enough staff.

C (16:12)

As a result, conditions deteriorated. Hill says the state was sued over this issue several times during the hospital's history. Old records provide evidence of abuse, even murder, but no staff or patients ever faced prosecution.

E (16:27)

We run across stuff constantly of patients being killed, sometimes by staff, sometimes by each other. But here you're going for a witness, and no one in the building is mentally competent.

C (16:40)

In 1985, staff found one patient strangled in her bed sheets.

E (16:45)

The medical examiner's report hints at the desert command and say it doesn't look like suicide.

C (16:51)

Tour guides have to memorize story after story like this. The script was so hard to read, Lowther almost didn't take the job.

F (16:58)

And I put it away and told my husband, I can't do this. I can't do this. This is too dark, this is too sad, this is too horrible. I can't do this.

C (17:05)

Then she saw something about the Holocaust on tv.

F (17:08)

And I'm like, now how can I teach the Holocaust and not teach this? And then I picked the script back up and like, yeah, okay, I'll come and do this, because this, this story needs to be told too.

C (17:32)

Back in Georgia, a man named Edwin Atkins unlocks a glass display case and lifts out a stack of musty old papers and pamphlets.

G (17:40)

This is the actual report of the lunatic asylum in the year 1887. Now this gives you every little bit of detail.

C (17:50)

Atkins is a former Paramount movie producer and a lifelong collector of rare books and historical artifacts, especially artifacts related to Central State Hospital. For him, the quest to piece together the asylum's history is deeply personal.

G (18:05)

My great grandmother was put there in the late 1800s, and I found one picture of her. And when I cleaned out my grandmother's attic in the 70s, I found a letter that said, when she died, to the Central State, please do not bury her there. We're going to take her to Bonaventure. That was the first time that I knew that a great grandmother was there. And I have not yet been able to get any information from the state or the archives or anywhere.

C (18:33)

Atkins isn't alone. Lots of Georgians have run into dead ends searching for information about ancestors sent to Milledgeville. Atkins created a Facebook group, Friends of Central State Hospital, to serve as a digital archive and encourage information sharing. And he set out to learn everything he could about the place his great grandmother lived and died. Eventually, he uncovered some answers.

G (18:58)

My great grandfather was a prominent real estate guy in Savannah. Real big guy with a lot of money and wanted a son to carry on the business. Well, the wife, Betty, gave him two daughters that lived and then a baby that died and then a son that lived for about a year and died. So after the four babies, two which died, he had a baby with the housekeeper and she went to Central State.

C (19:27)

Atkins says this type of story is all too common among women sent to asylums. Too many ended up there not because they were mentally ill, but because they were vulnerable.

G (19:37)

If you wanted to get rid of your wife for some reason, that was the way to do it. It only took like two people to verify.

C (19:54)

Today, Atkins two story 19th century home is crammed with relics from Central State Hospital. Original patient reports, consultant sheets, employee handbooks, even an old doctor's diary.

G (20:05)

Okay, so we're going down these steps from this 1850 house.

C (20:10)

Atkins leads the way down his deep front steps and unlocks his basement apartment turned bookshop.

G (20:15)

We're going into what is the Slate Row rare bookstore, and we're going to look at the bookstore because it has a lot of information about Central State.

C (20:26)

In the shop's back room, he unzips a black leather doctor's bag filled with jangling instruments. Warehousing of patients had become the norm at asylums during this era. And in the 1940s and 50s, a batch of strange and disturbing new treatments took off in the United States. Atkins has a wealth of knowledge about them all. He opens the lid of a small walnut chest. A portable electroshock therapy machine and demonstrates how it works.

G (20:56)

They had a dial where it would go up with the amount of current that you were putting into the patient. And it's a very elaborate looking machine. And then this cylinder went into this compartment here. And I'm not sure exactly how this worked, but it sure did send a lot of electricity into your brain.

C (21:25)

In 1946, American neurologist Walter Freeman II completed the first transorbital or ice pick lobotomy. A frightening operation severing brain nerves. In an attempt to stabilize patient mood swings, the doctor would tap a tool resembling an ice pick past the eye, through the eye socket and into the brain.

G (21:45)

Here are the actual tools. This pick would be placed in the orbital eye, right between the eye and the skull and go up into the brain.

C (21:59)

But lobotomies could prove devastating for patients.

G (22:02)

It has little marks as to how deep it should go into the brain. And it would destroy the front lobal, you know, the front section, and basically turn them into a vegetable.

C (22:17)

Some patients seemed to improve, at least in the short run. But the procedure was extremely risky. And patients sometimes emerged with a completely different personality or slipped into a childlike state. Others didn't survive at all. In 1954, the Food and Drug administration approved Thorazine, the first ever antipsychotic drug. It burst on the scene with a tremendous wave of optimism. Medical journals celebrated it as a chemical lobotomy and predicted a new era of medicine. One where researchers would discover a brain based cause for mental illness and cure it once and for all with just the right regimen of drugs and dosing. But Thorazine came with a number of side effects like dizziness, drowsiness and weight gain. And the medication was often used more to control patients than to improve their quality of life. Atkins reads a post from a member of his Facebook group. A former patient committed to Central state in the 60s.

G (23:16)

I was 15 years old at the time and I was there because of a family problem. It was anything but nice. And we were warehoused and given a lot of mainly thorazine. So we were out of the workers hair. The attendants mainly sat and played spades, a card game. There was no therapy. There was nothing to read, There was no one to talk to. Most people were like zombies.

C (23:48)

In 1959, the Atlanta Constitution published an expose from reporter Jack Nelson labeling Central State a snake pit. Nelson found for 15,000 patients. There were only 48 doctors and not a single psychiatrist. Nelson's investigation joined a growing list of damning coverage, highlighting rampant abuse and neglect in US Institutions. By now, the standard of treatment provided at most state hospitals was anything but moral. The asylum experiment had failed. Faced with asylum horror stories, reformers started advocating for deinstitutionalization, moving patients from massive state hospitals to smaller outpatient clinics.

H (24:33)

The time has come for a great national effort. New medical, scientific, and social tools and insights are now available.

C (24:42)

The new vision found a champion in president John F. Kennedy.

H (24:46)

With respect to mental illness, our chief aim is to get people out of state custodial institutions and back into their communities and homes without hardship or danger.

C (24:57)

Kennedy's own sister, Rosemary, wound up in an institution after a disastrous lobotomy left her barely able to walk or talk. Kennedy made his pitch to Congress in February 1963.

H (25:10)

I have sent to the Congress today a series of proposals to help fight mental illness and mental retardation. These two afflictions have been long neglected. They occur more frequently, affect more people, require more prolonged treatment, cause more individual and family suffering than any other condition in American life. It has been tolerated too long.

C (25:35)

After that, Congress passed Kennedy's community Mental Health act, which pledged $150 million in federal grants to help get 1500 community mental health centers off the ground. After Kennedy's death, Lyndon Johnson carried forward the community treatment torch. Johnson's newly established Medicaid program blocked hospitals with more than 16 beds from receiving Medicaid payments. TV journalist Geralda Rivera brought one particularly harrowing account to the American public. Rivera got a tip from a former doctor at Willowbrook State School, a New York institution for people with developmental disabilities.

H (26:14)

The doctor told me he'd just been fired because he'd been urging parents with children in one of the buildings, building number six, to organize so they could more effectively demand improved conditions for their children.

C (26:25)

The doctor offered to smuggle Rivera and his camera crew inside.

H (26:29)

The doctor had warned me that it would be bad. It was horrible. There was one attendant for perhaps 50 severely and profoundly children lying on the floor naked and stuck, smeared with their own feces. They were making a pitiful sound, a kind of mournful wail that it's impossible for me to forget. This is what it sounded like. But how can I tell you about the way it smelled? It smelled of filth, it smelled of disease, and it smelled of death.

C (27:06)

Rivera's segment aired on February 2, 1972, and it shook the American public to its core. Those haunting and disturbing images looked like something from a Nazi concentration camp, not from the free western world. Across the country, state hospitals started Downsizing and shuttering. Back in Georgia, Central state tour guide Walter Reynolds says the state started to transfer patients from central state hospital to. To two sister hospitals in Thomasville and Bainbridge. The patient population dropped from 12,000 to less than 10,000 over the next seven

B (27:42)

years, and it just steadily declines thereafter.

C (27:46)

The hospital started to collapse in on itself.

B (27:49)

They close one ward and then one wing and then one building, and next thing you know, it's all of these buildings are going dormant.

C (27:58)

At one point, Reynolds visited some of these closed off buildings. The rooms looked eerily undisturbed.

B (28:04)

And when they walked out, they just left everything where it was. Perfectly preserved. Time capsule of what was going on that day. Notes for the following week. Their pen right on top of it, an empty can of coke sitting there, fridge still humming, lights still on, radio still running. They just got up and walked out, and that was it.

C (28:26)

By the 1990s, only about 3,000 patients remained at Central state Hospital. Across the country, other state institutions were on the same trajectory. The number of patients living in state psychiatric hospitals plummeted more than 75% from the 1950s to the 1980s. For many, it was a moment of great triumph.

B (28:45)

We reintegrate individuals into society. There were a lot of people that had very mild mental deficiencies that, that were relegated to the asylums. You had individuals with down syndrome, folks that today we know are perfectly capable of functioning in society.

C (29:06)

One woman released in the 70s had been sent to Central state just for having seizures.

B (29:11)

When she was finally released, my great grandmother invited her into her home, and she lived with my great grandmother until the day that mamu passed. And we always just referred to her as Aunt Helen. I was 17 or 18 years old before I learned that aunt Helen was in fact, not biologically related and that she was a former patient of the state hospital.

C (29:38)

But many other patients weren't so lucky. They received little support and often met with community backlash.

B (29:45)

The NIMBYs, the not in my backyard crowd, they come out in full force anytime that someone's trying to open up a group home, you know, saying, we don't want these type of people in our community. We don't know anything about them. They're dangerous.

C (29:59)

On top of that, the money and support for community mental health centers fizzled out, and by the 1980s, less than 100 remained open. When the Trans Allegheny lunatic asylum closed in Weston, West Virginia in 1994, many patients had nowhere to go. Tour guide Greg Hill says many of their families were gone. Orr had wanted to get rid of them in the first place.

E (30:21)

One guy was here, 72 years old, said, you can't take me out of my home. They put him in a nursing home. He'd been here since age 12.

C (30:30)

Staff sent patients deemed criminally insane to nearby Sharp Hospital, a 200 bed psych ward. They also sent along people doctors said could never be rehabilitated. But most had to find their way on their own, Hill says.

E (30:44)

So really, they just opened the doors and said, get out of here.

C (30:48)

Patients left the asylum vastly unprepared for the challenges of life on the outside. In the 1980s, the homeless population exploded in West Virginia and everywhere else in the United States. According to one estimate, the number of people living on the streets almost doubled between 1984 and 1987.

B (31:07)

Ultimately, we ended up with homeless people, people who had nowhere to go and were, you know, very, very sick. They didn't have community mental health centers. They didn't have the old asylums.

C (31:18)

The US Prison population also started ballooning about this time. During the 1980s, the number of inmates increased 134%.

B (31:26)

Now they had jails and prisons. They have emergency rooms, and they had the streets.

C (31:31)

That's Kenneth Rosenberg. He's an addiction psychiatrist and the author of An Intimate Journey into America's Mental Health Crisis. He argues deinstitutionalization really just ended up being trans institutionalization, taking people from one

B (31:46)

bad institution, the asylums, to a worse institution, the prisons, the jails, and the streets.

C (31:52)

Correlation doesn't equal causation, and there are a lot of factors behind American homelessness and mass incarceration. But it's safe to say lots of people who would have landed in asylums in the past are now languishing behind bars or living on the streets. One 2013 study found deinstitutionalization didn't directly translate to trans institutionalization between 1950 and 1980, but authors traced 4 to 7% of US prison and jail population growth over the following 20 years back to this trend. Today, Rosenberg says about 25% of people living on the streets suffer from poorly treated or untreated mental illnesses. He encounters them every day on his way to work in New York City.

B (32:36)

I don't have to go very far to find a homeless person who has a serious mental illness just lying on the street, you know, begging for money, or, you know, just really in great distress.

C (32:46)

One psychiatrist Rosenberg interviewed told him the United States now has just 2 to 3% of the public psychiatric beds available roughly 60 years ago. Others say there are more beds than ever, but they're far flung, poorly tracked and difficult to access. Spread out among a patchwork of private psychiatric hospitals, general hospital psych units, residential treatment centers and nursing homes. In West Virginia, Tour guide Amy Lowther says the country's gone from one extreme to the other.

F (33:14)

We went from having everyone locked up, even if they didn't have anything mentally ill wrong with them, to almost having no one locked up. I mean, we're.

C (33:23)

Laws passed in response to asylum era abuses make it extremely difficult to have someone involuntarily committed. Lowther argues that also makes it much harder to get people the help they need.

F (33:34)

Somewhere in between then and now is the answer. We need to have more mental health on the ground.

C (33:48)

Clearly, something needs to change. Roughly 140,000 mentally ill Americans or more live on the streets or in emergency housing without decent care because of over 100 years of choices. And one key choice was to move away from the ideas that inspired the original Quaker moral treatment. That approach worked really well and our culture could choose to return to it. Moral treatment wasn't about the size of the building. It was about recognizing that people are made in the image of God. When doctors, when our culture lost sight of that foundational fact, well, we got the kind of asylums that deserved to be shut down, asylums that should never have been allowed to operate, institutions that made a mockery of the word asylum. Back at Central State, 170 psychiatric patients still live in the Cook Building, but many of the historic halls are crumbling and condemned. Walter Reynolds believes these old buildings could be part of a new solution.

B (34:56)

These could be set up and equipped as places that were safe for in house treatment. In community treatment, it could be a blended.

C (35:06)

Either way, Reynolds argues it's time to reconsider completely abandoning the asylum system.

B (35:12)

It would be tremendously beneficial as a society for there to be someplace safe that people could go to get the treatment that they need. We've got to get really serious as a nation about what our priorities are and about the lengths that that we should go to to protect the most vulnerable among us.

A (35:48)

Grace Snell reported and wrote this episode with additional reporting from Emma Frear. Lee Jones was the editor and Ben Jaicker produced it. I'm Les Sillers. Please don't forget to rate and review us on your podcast app and if you enjoyed this episode. The best way to help ensure that we're able to tell more stories like this is to share it with someone.

E (36:07)

Thanks.

A (36:08)

And thanks for listening. We'll see you next time.

E (36:23)

Sa.