Thus, when the remains of the pampered elites are excluded from the equation, graveyards from all the world’s great agricultural civilizations through to the Industrial Revolution tell an enduring tale of systematic nutritional deficiencies, anemia, episodic famines, and bone deformations as a result of repetitive, arduous labor, in addition to an alarming array of horrendous and sometimes fatal work-induced injuries.

Thomas DeBaggio, a writer and horticulturist, was even able to publish two insightful memoirs about his own early-onset Alzheimer’s before the disease killed him at the age of sixty-nine. But most patients are frightened or mortified by the knowledge of what is befalling them. Some continue to be severely terrified as they lose their intellectual competences and bearings and find themselves in a world increasingly fragmented and chaotic. But the majority, I think, become calmer with time as they perhaps start to lose the sense of what they have lost and find themselves shifted into a simpler, unreflective world.

Kurt Goldstein, studying brain-damaged soldiers during World War I, was moved from his original, deficit-based point of view to a more holistic, organismal one. There were never, he believed, just deficits or releases; there were always reorganizations, and these he saw as strategies (albeit unconscious and almost automatic) by which the brain-damaged organism sought to survive, although perhaps in a more rigid and impoverished way.

Sadly and ironically, soon after I arrived in the 1960s, work opportunities for patients virtually disappeared, under the guise of protecting their rights. It was considered that having patients work in the kitchen or laundry or garden, or in sheltered workshops, constituted “exploitation.” This outlawing of work— based on legalistic notions of patients’ rights and not on their real needs— deprived many patients of an important form of therapy, something that could give them incentives and identities of an economic and social sort. Work could “normalize” and create community, could take patients out of their solipsistic inner worlds, and the effects of stopping it were demoralizing in the extreme. For many patients who had previously enjoyed work and activity, there was now little left but sitting, zombielike, in front of the now-never-turned-off TV.

We forgot the benign aspects of asylums, or perhaps we felt we could no longer afford to pay for them: the spaciousness and sense of community, the place for work and play, and for the gradual learning of social and vocational skills—a safe haven that state hospitals were well equipped to provide.