The mid-nineteenth century in North Carolina marked a time of great change in the methods of caring for the mentally ill. Documenting the American South recognizes Mental Health Month by highlighting Dorothea Dix's advocacy for formal, humane institutional care for those suffering from mentally illness.

As noted by the North Carolina Center for Public Policy Research, North Carolina relied on "families as caregivers and ad hoc charitable and community-based efforts" to deal with the mentally ill until the mid 1800s (p. v). Despite the push by other states to develop and build asylums, North Carolina hesitated "primarily because the cost of constructing an asylum was considered too high." North Carolina was thus the second-to-last of the original 13 colonies to pass legislation allowing for the construction of a state hospital (p. vi). The efforts of Dorothea L. Dix were of paramount importance in swaying legislators to consider the cost savings (and fundamental humanity) of treating the insane. Dix began as a teacher in New England, but upon discovering the plight of the insane while teaching in a prison in Boston, she began a life-long crusade to change the care of the mentally ill.

Dix addresses the North Carolina General Assembly in her 1848 Memorial Soliciting a State Hospital for the Protection and Cure of the Insane. As the North Carolina Division of Mental Health notes in their online biography of Dix, this address was not unique: she traveled from state to state to "try to convince those in authority of the need of improvement in the care of the mentally ill (North Carolina Division of Mental Health)." As an "advocate of those who cannot plead their own causes," Dix spoke for "hundreds of wailing, suffering creatures, hidden in your private dwellings, and in pens and cabins—shut out, cut off from all healing influences" (p. 3). Chiding North Carolina for being the last state of the original thirteen colonies, "save the small territory of Delaware, to make provisions for the care and cure of her insane citizens," Dix appeals to "liberal and humane hearts" to establish care for the mentally ill (p. 4).

At the time that Dix was lobbying the General Assembly, North Carolina offered "four methods of disposing of her more than one thousand insane, epileptic, and idiot citizens . . . . In the cells and dungeons of the County jails, in comfortless rooms and cages in the county poor-houses, in the dwellings of private families, and by sending the patients to distant hospitals, more seasonably established in sister States" (p. 4). Much of her 48-page Memorial focuses on discussing the inadequacy of each of these methods. Using county prisons to house the ill is "subverting the uses for which these prisons are constructed" and "placing the innocent on a level with the guilty making misfortune and crime, disease and health go hand in hand" (p. 6). Unlike the felon who can look forward to completing his sentence, the mentally ill patient "anticipates no season of liberty" (p. 6). Dix lists the prisons in North Carolina, noting the conditions and the number of mentally ill persons held there.

North Carolina's poor-houses provide an even worse shelter for the mentally ill, Dix argued, for while a jail might be "well built" and kept in "good order," "[t]he reverse exists" for many poor-houses (p. 13). Dix points out that even the "County poor-house" located "a few miles from Statesville" which stands as a "model of neatness, comfort, and good order" is "no fit place for the insane" (p. 17). Both jails and poor-houses, faced with the challenges of the mentally ill, usually resort to restraint and neglect, which degrades both the human being and the institution.

Like jails and poor-houses, families also struggles with the treatment and care of the insane, who were "thrown in to sorrow and trouble unequaled through the affliction and sore perplexities arising out of care over the demented, the epileptic, and the maniac" (p. 26). The only remaining option, Dix noted, was removing the ill to other states, making North Carolina "dependent upon other States for her afflicted children, while in possession of ample means to succor and heal their maladies within her own borders" (p. 29). Dix provides several charts displaying specific out-of-state asylums' cure and improvement rates, comparisons of the cost of treating the mentally ill after sustained illnesses versus treating them at the first sign of disease, and the profits from an out-of-state asylum's working farm. Dix aims to show the cost effectiveness of building proper asylums in North Carolina, asylums which can treat—and potentially cure—the mentally ill. She proposes guidelines for proper care, including exercise, proper nursing, and "moderation in all things" (p. 43). Finally, Dix calls upon the legislators to use their "God-like influence" wisely to benefit "the present and future destiny of hundreds, nay of thousands, who pine in want and misery, under privations and sufferings" (p. 48). The decision to establish care, Dix concludes, is the only appropriate response to the demands of "justice," "humanity" and "unquestionable civil obligation" (p. 48).

Her efforts, along with those of other like-minded advocates, including North Carolina General Assembly Representative Kenneth Rayner, led to the beginning of construction in 1854 of what was referred to at the time as the Asylum for the Insane of North-Carolina. By 1856 the institution welcomed its first inhabitants. Only two other asylums for the mentally ill were approved and built before the turn of the twentieth century in North Carolina: Broughton Hospital in Morganton and Cherry Hospital in Goldsboro. Cherry Hospital, which opened in 1880, was designated the "Asylum for the Colored Insane" and remained the only mental hospital available to African Americans in North Carolina "[u]ntil the implementation of the Civil Rights Act 85 years later" ("Reforming Mental Health Reform," p. vi).

Works Consulted: North Carolina Center for Public Policy Research, "Reforming Mental Health Reform: The History of Mental Health Reform in North Carolina"; North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services, "Biography of Dorothea Lynde Dix," accessed 25 April 2010.