1776–1840
In early America what happened to a person experiencing serious mental health challenges largely fell to families. A person with financial resources and a family able to provide support might remain at home. For people who were poor, without family support, or whose needs became too difficult for families to manage, the options were far more limited. They could end up in an almshouse or poorhouse, a jail, a hospital, or another form of confinement.
This meant that from the nation’s earliest years, the treatment of people experiencing mental health challenges was intertwined with poverty, social status, race, and access to resources. Thus, a person’s experience was not determined by their condition alone. A family’s financial means and standing in the community could determine whether someone was cared for privately or placed in a public institution. Black Americans, whether enslaved or free, had little to no access to medical care, including mental health care. The inequities that shaped America fed into how the mental health system was built.
Before There Was a Mental Health System
When the United States was founded in 1776, families were the primary caregivers. Churches and local communities sometimes provided assistance. Physicians treated some people privately, but medical understanding of mental health challenges was extremely limited, and treatment was generally available only to people who could afford it or otherwise gain access. For everyone else, local governments relied heavily on institutions that had not been created to provide mental health care. Almshouses and poorhouses were established primarily for people who were poor, elderly, sick, disabled, orphaned, or otherwise unable to support themselves. People experiencing serious mental health challenges were placed in these same institutions, often with little or no specialized care. Jails also became places of confinement, particularly when someone was considered disruptive, dangerous, or simply could not be cared for elsewhere. Mental health challenges therefore became entangled with broader judgments about dependency, behavior, morality, and who society believed deserved public support.
The Beginnings of Mental Health Care
There were early attempts to create more specialized forms of care. Pennsylvania Hospital, founded in Philadelphia in 1751, was among the first hospitals in the American colonies to admit people experiencing mental health challenges. In Virginia, the Public Hospital for Persons of Insane and Disordered Minds opened in Williamsburg in 1773 and became the first public institution, in what would become the United States, created specifically for people with serious mental health needs. These institutions represented an important shift that mental health challenges required a distinct public response rather than confinement in a jail or poorhouse. But early treatment could still be harsh with people being restrained, isolated, or subjected to medical practices based on theories that would now be considered deeply misguided.
One of the most influential physicians of the period was Benjamin Rush, a signer of the Declaration of Independence who became known as an early leader in American psychiatry. Rush argued that mental health conditions should be understood as medical conditions rather than a moral failing or evidence of supernatural forces. His leadership helped move American thinking toward the idea that people experiencing mental health challenges could be treated.
Yet Rush also promoted treatments such as bloodletting and developed restraint devices, reflecting both the possibilities and severe limitations of medical knowledge at the time. The emergence of medicine did not automatically produce humane care.
By the late eighteenth and early nineteenth centuries, another philosophy was beginning to influence mental health care.
Known as moral treatment, the approach developed largely in Europe and emphasized humane surroundings, routine, meaningful activity, social interaction, and greater respect for the person receiving care. Rather than relying primarily on punishment or physical restraint, advocates argued that environment and human relationships could contribute to recovery.
The philosophy began influencing American institutions during the early nineteenth century. It represented a profound change in thinking, which was that people experiencing mental health challenges were increasingly being viewed as people capable of improvement rather than simply individuals who needed to be controlled or confined.
But access to more humane care was unequal. Hospitals that specialized in more humane approaches did not replace jails or almshouses. They existed alongside them. Black Americans still had even less access to healthcare, with many institutions even in the North refusing to serve Black people.
The Growing Need for Reform
As the nation grew, so did concern about the conditions in which people experiencing serious mental health challenges were living. States began establishing publicly funded psychiatric institutions, including Worcester State Hospital in Massachusetts, which opened in 1833. These institutions reflected growing acceptance of the idea that the government had some responsibility for the care of people with serious mental health needs. The tension was growing as large numbers of people continued to live in institutions where there was little or no treatment.
By the 1840s, reformers would begin documenting those conditions and demanding a different public response. Dorothea Dix would become the most prominent figure in that movement, traveling to jails and poorhouses and bringing public attention to the treatment of people experiencing mental health challenges. Her work would help launch the first major national movement for mental health reform.
From the earliest years of the United States, the country has wrestled with questions that remain issues today. The separation of people experiencing mental health challenges from their communities, the connection between poverty and institutionalization, unequal access to care, and the continuing struggle between care with dignity and confinement.
Those patterns would shape the next chapter of America’s mental health history and the reform movement that was about to begin.
The Foundations of Mental Health in Early America | 1776–1840
How early American beliefs about mental health challenges, poverty, morality, and social order shaped the country’s first responses to people experiencing mental health challenges.
- 1751:Pennsylvania Hospital is founded and later becomes one of the first hospitals in the colonies to admit people experiencing mental health challenges.
- 1773:Virginia opens the first public institution in what would become the United States, specifically established to care for people with serious mental health needs.
- Early America: Families provide most care; people without resources may be sent to almshouses, poorhouses, jails, or other institutions.
- Early 1800s:“Moral treatment” begins influencing American institutions, emphasizing more humane care, routine, activity, and social interaction.
- 1833: Worcester State Hospital opens in Massachusetts as states increasingly assume responsibility for mental health care.