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 is one of those explanations that feels settled, the kind even careful people repeat: that sometime back we tore down the asylums, turned out the patients who had nowhere else to go, and that is why there are people talking to themselves on our sidewalks today. It is a tidy story, and parts of it are true.
We did empty the hospitals. It was often done coldly, and the community care that was promised to replace them was mostly never built. So this is not 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.
Start by agreeing with the story, because the first half of it is accurate, and it happened here as much as anywhere.
North Carolina built four great state hospitals, one for each corner of the state. The one for our western counties is Broughton Hospital in Morganton, an hour east of Asheville, opened in 1883 and expanded for decades until its campus could hold thousands. Walk it today and you find a few hundred patients on grounds built for many times that number.
The same emptying happened across the country, and the scale of it is hard to overstate. In 1955, the nation's public mental hospitals held about 559,000 people. By 1975 that had fallen to roughly 200,000, with the steepest drop, nearly 60 percent, packed into the single decade between 1965 and 1975. By 1980, about three-quarters of the 1955 population was gone.
New drugs made shorter stays possible. Courts narrowed who could be held against their will. States, eyeing the cost of the hospitals, were glad to discharge. Whatever you think of it, the emptying was real, and it was largely finished by the late 1970s.
The hospitals emptied through the 1960s and 70s. Mass homelessness did not arrive until the 1980s.
Hospital figures are real counts; the homelessness line is a schematic of the documented trend, not a year-by-year count, since no national tally existed before the late 1980s.
Here is where the story breaks. The hospitals had largely emptied between 1955 and 1975. Mass homelessness, the kind we would recognize now, did not appear as a national crisis until the early 1980s, and it did not seize the country's attention until the middle of that decade.
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 a great many went to the cheapest housing the country had: the single-room-occupancy hotels, the SROs, where 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 twenty years, that thin floor held.
Then, in the late 1970s and across the 1980s, three things happened close together, and the floor gave way.
The cheap rooms that had quietly housed the discharged were torn down by the hundreds of thousands. The federal housing money that might have replaced them was cut roughly in half. And a federal review of the disability rolls stripped benefits from hundreds of thousands of people, many of them the very people who had left the hospitals years before.
So the room vanished, the rent help shrank, and the small disability check that had paid for the room was canceled, often all within a few years of one another. That is when people hit the street. Not when the hospital discharged them. When the housing that caught them was taken away.
None of this means mental illness had nothing to do with it.
Emptying the hospitals created a large group of people who were unusually easy to push over an edge: poor, sometimes needing specialized care, often without family nearby or the wherewithal to fight a brutal housing market. When the cheap rooms disappeared, they 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 set by how much low-cost housing we destroyed and how little we replaced. Illness chose the names. The bulldozers and the budget set the count.
It is more comforting, in a way, to blame them. It turns homelessness into the lingering side effect of one old decision about the mentally ill: something finished, far away, and nobody's current fault. A mistake we cannot take back.
The truer story is harder, and also more hopeful. We did not fail by letting people out of hospitals. We failed by tearing down the rooms they could afford and cutting the checks that paid for them, and in much of the country, Asheville included, we are still failing that way now. A thing we are still doing is a thing we can choose to stop.