Prisons Are Replacing Psychiatric Hospitals: Andrew Scull on the Failures of Mental Health Policy

In a conversation on Lex Fridman's podcast, psychiatric historian Andrew Scull raised a deeply troubling reality: the three largest "inpatient psychiatric treatment centers" in the United States today are not hospitals — they are jails. Los Angeles County Jail, Cook County Jail in Chicago, and Rikers Island in New York. Behind this claim lies a deep fracture left by decades of failed public policy.

People with Serious Mental Illness Are Being Systematically Abandoned

Scull points out that people with serious mental illness die, on average, 15 to 25 years earlier than the general population — and that gap is not narrowing. It is growing. He is careful to note that the blame cannot be placed entirely on psychiatry itself. The larger problem lies in public policy, which has effectively abandoned the treatment of people with severe mental illness.

The consequences of that abandonment play out directly on city streets. Scull uses the striking phrase "sidewalk psychotics" to describe people caught in a revolving door between brief hospitalizations, sleeping rough, and incarceration. They have no stable place to land, and so they drift endlessly between these three situations.

When prisons become de facto psychiatric facilities, the absurdity of the situation becomes impossible to ignore. Jails were never designed to handle serious mental illness. Locking a patient in a cell is neither treatment nor humane care.

A Dark Return to the Age of the Asylum

Facing this reality, Fridman posed a sharp question: does this mean we are retreating, in some dark sense, back to the era of the asylum? Scull's answer reveals a profound historical irony.

He acknowledges that asylums carry a terrible reputation, and that he himself has written extensively about how that reputation was formed. But he asks people to remember a commonly forgotten starting point: asylums were originally built out of enormous optimism.

Asylums Once Carried the Optimism of a Cure

Scull reconstructs the original vision behind the asylum. The reformers of the era wanted to rescue mentally ill people from attics and jails and provide them with a "therapeutic environment." The core of this approach was not to drive the "demons" from patients' minds, but to guide them toward productive labor and a degree of self-control — to keep the illness "within certain bounds."

The earliest psychiatrists — who called themselves "alienists" — held remarkable confidence. They believed that if patients could be admitted early, it might be possible to cure 60%, 70%, 80%, or even more of them. Scull emphasizes that the asylum was built on this optimism: many conditions, they believed, were caused by environment, and the previous practice of beating and brutalizing patients like animals only made things worse. A humane environment, by contrast, might itself bring about recovery.

The term "alienists" itself reflects a 19th-century framework for understanding mental illness — the mentally ill were seen as people "alienated from their own reason," not as moral failures or simply dangerous individuals. The "moral treatment" movement that emerged during this period advocated replacing physical punishment and confinement with humane daily routines, regular labor, and social interaction. Its leading figures included William Tuke in England and Philippe Pinel in France. However, as asylum populations grew explosively toward the end of the 19th century — far exceeding designed capacity — the early therapeutic ideals rapidly gave way to the simple functions of custodial containment and control. Severe shortfalls in staff, combined with the accumulation of chronic patients, transformed asylums into what Scull calls "museums for the storage of disease." The early optimistic cure-rate figures vanished, and some later scholars noted that those high recovery statistics had been subject to severe selection bias from the start.

"Community Care" Was a Shell Game Without a Pea

Deinstitutionalization — which began in the 1950s and accelerated sharply after the late 1960s — closed vast numbers of asylums. Scull notes that the justification offered for this process was a promise of some "miraculous" alternative: community care.

In his view, community care turned out to be "a shell game without a pea" — a classic con. The promised community facilities were never truly built. For patients with the most severe mental illnesses, there simply were no community-based institutions capable of replacing the asylum. And so the patients released from the old institutions ended up on the streets and in prisons.

The deinstitutionalization movement was driven by the convergence of several forces: the arrival of first-generation antipsychotic drugs like chlorpromazine in the 1950s created optimistic expectations that medication could manage symptoms on an outpatient basis; the rise of the civil rights movement called the legality of involuntary commitment into question; and fiscal pressures gave state governments ready justification for closing expensive state hospitals. In 1963, the Kennedy administration passed the Community Mental Health Centers Act, planning to establish 2,000 community mental health centers across the country — legislation that became the policy backbone of deinstitutionalization. But the plan was never fully realized. Funding remained chronically insufficient, and the centers that were built typically served patients with mild to moderate conditions, lacking the capacity to handle complex, severely ill patients dealing with homelessness or co-occurring substance abuse. Psychiatric bed counts in U.S. state hospitals fell from roughly 550,000 in 1955 to fewer than 100,000 by the 1990s, and the promised community resources never filled the gap.

A Policy Dilemma Worth Taking Seriously

Scull's account traces a clear and sobering historical arc: from the optimism of the asylum era, to its total discrediting and dismantling, to the broken promise of community care, and finally to the point where prisons have informally absorbed the mentally ill.

The value of this conversation is not a simple nostalgia for the old system. It is an exposure of a neglected structural truth: when a society tears down old institutions without genuinely delivering the alternatives it promised, the most vulnerable people are pushed toward the places least equipped to hold them. For anyone who cares about public health and social policy, this is a warning that demands to be taken seriously.