Deinstitutionalisation
Encyclopedia
Deinstitutionalization or deinstitutionalization is the process of replacing long-stay psychiatric hospital
s with less isolated community mental health service
for those diagnosed with a mental disorder or developmental disability
. Deinstitutionalization can have multiple definitions; the first focuses on reducing the population size of mental institutions. This can be accomplished by releasing individuals from institutions, shortening the length of stays, and reducing both admissions and readmission. The second definition refers to reforming mental hospitals' institutional processes so as to reduce or eliminate reinforcement of dependency, hopelessness, learned helplessness, and other maladaptive behaviors.
According to psychiatrist and author Thomas Szasz (1920–present), deinstitutionalization is the policy and practice of transferring homeless, involuntarily hospitalised mental patients from state mental hospitals into many different kinds of de facto psychiatric institutions funded largely by the federal government. These federally subsidised institutions began in the United States and were quickly adopted by most Western governments. The plan was set in motion by the Community Mental Health Act
as a part of John F. Kennedy's legislature and passed by the US Congress in 1963, mandating the appointment of a commission to make recommendations for "combating mental illness in the United States" (Thomas Szasz, 'Coercion as Cure', p. 34).
In many cases the mass deinstitutionalization of the mentally ill in the Western world from the 1960s onward has translated into policies of "community release". Individuals who previously would have been in mental institutions are no longer supervised by health care workers. Some have considered deinstitutionalization to be a failure.
, they became overstretched, non-therapeutic, isolated in location, and neglected in practice.
, many patients even starved to death.
The first community-based alternatives were suggested and tentatively implemented in the 1920s and 1930s, although asylum numbers continued to increase up to the 1950s. The movement for deinstitutionalization came to the forefront in various countries in the 1950s and 1960s.
The prevailing public arguments, time of onset, and pace of reforms varied by country. Class action lawsuits in the United States, and the scrutiny of institutions through disability activism and antipsychiatry, helped expose the poor conditions and treatment. Sociologists and others argued that such institutions maintained or created dependency, passivity, exclusion and disability, which caused people to become institutionalised.
There was an argument that community services would be cheaper, and it was suggested that new psychiatric medications made it more feasible to release people into the community.
A key text in the development of deinstitutionalization was Asylums
by Erving Goffman
.
Unfortunately groups such as mental health professionals, public officials, families, advocacy groups, public citizens, and unions held differing views on deinstitutionalization.
and early intervention teams
) in the community. Costs have been reported to be as generally equivalent as inpatient hospitalisation, even lower in some cases (depending on how well or poorly funded community alternative are). Some regions introduced laws enabling forced medication in the community for those with psychiatric diagnoses.
Although deinstitutionalization has been positive for the majority of patients, it also has severe shortcomings.
Expectations that community care would lead to fuller social integration have not been achieved; many remain without work, have limited social contacts and often live in sheltered environments.
New community services were often uncoordinated and unable to meet complex needs. Services in the community sometimes isolated the mentally ill within a new ghetto
, where service users meet each other but have little contact with the rest of the public community. It has been said that instead of "community psychiatry", reforms established a "psychiatric community".
Existing patients were often discharged without sufficient preparation or support. A greater proportion of people with mental disorders became homeless or went to prison
. Widespread homelessness
occurred in some states in the USA and some other countries. Families can often play a crucial role in the care of those who would typically be placed in long-term treatment centers. However, many mentally ill people are resistant to such help due to the nature of their conditions. The majority of those who would be under continuous care in long-stay psychiatric hospitals are paranoid and delusional to the point that they refuse help and do not believe they need it, which makes it difficult to treat them.
Moves to community living and services led to various concerns and fears, from both the individuals themselves and other members of the community. Over a quarter of individuals accessing community mental health services in a US inner-city area are victims of at least one violent crime in a year, a proportion eleven times higher than the inner-city average.
The proportion is many times greater in every category of crime, including rape/sexual assault, other violent assaults, and personal and property theft. The rates are similar in those with developmental disabilities.
Despite perceptions by the public and media that people with mental disorders released into the community are more likely to be dangerous and violent, a large study indicated that they were no more likely to commit violence than those in the neighborhoods (usually economically deprived and high in substance abuse and crime) to which they typically lived.
Findings on violence committed by those with mental disorders in the community have been inconsistent and related to numerous factors; a higher rate of more serious offenses such as homicide have sometimes been found but, despite high-profile homicide cases, the evidence suggests this has not increased over the period of deinstitutionalization. The aggression and violence that does occur, in either direction, is usually within family settings rather than between strangers.
, the number of hospital beds has risen steadily over the last few decades.
In Hong Kong
, a number of residential care services such as half-way house
s, long-stay care homes, supported hostel
s are provided for the discharged patients. In addition, a number of community support services such as Community Rehabilitation Day Services, Community Mental Health Link, Community Mental Health Care, etc. have been launched to facilitate the patients to re-integrate into the community.
established a reconciliation
initiative in 2005 in the context of ongoing compensation
payouts to ex-patients of state-run mental institutions in the 1970s to 1990s. The forum heard of poor reasons for admissions; unsanitary and overcrowded conditions; lack of communication to patients and family members; physical violence and sexual misconduct and abuse; inadequate complaints mechanisms; pressures and difficulties for staff, within an authoritarian psychiatric hierarchy based on containment; fear and humiliation in the misuse of seclusion
; over-use and abuse of ECT
, psychiatric medication
and other treatments/punishments, including group therapy
, with continued adverse effects; lack of support on discharge; interrupted lives and lost potential; and continued stigma, prejudice and emotional distress and trauma.
There were some references to instances of helpful aspects or kindnesses despite the system. Participants were offered counseling to help them deal with their experiences, and advice on their rights, including access to records and legal redress.
Some developing European countries still rely on asylums.
had started Italian psychiatric reform
that terminated with the very end of the Italian state mental hospital system in 1998. The reform was directed towards the gradual dismantling of the psychiatric hospitals and required a comprehensive, integrated and responsible community mental health service. The object of community care was to reverse the long-accepted practice of isolating the mental ill in large institutions, to promote their integration in the community offering them a milieu which is socially stimulating, while avoiding subjecting them to too intense social pressures.
Numerous social forces have led to a move for deinstitutionalization. However, researchers generally speak of six main factors: criticisms of public mental hospitals, incorporation of mind-altering drugs in treatment, support from President Kennedy for federal policy changes in the treatment for those with mental illnesses, shifts to community based care, changes in public opinion of those with mental disabilities, and individual state's desire to reduce cost of mental hospitals.
The public's awareness of the conditions of mental institutions began to increase during World War II (WWII). During this period, conscientious objectors (COs) were assigned to alternative positions in which there were manpower shortages. Around 2,000 of them were assigned to fill job positions in understaffed mental institutions. In 1946, there was an expose in Life magazine detailing the shortfallings of many mental health facilities. This expose was be one of the first featured articles about the quality of mental institutions. Following WWII, articles and exposes about the mental hospital conditions would bombard popular and scholarly magazines and periodicals. In 1946, COs featured in the Life expose formed the National Mental Health Foundation, which was successful at convincing states to increase funding for mental institutions via public opinion support. 5 years later, the National Mental Health Foundation merged with the Hygiene and Psychiatric Foundation to form the National Association of Mental Health.
Another revelation during WWII relevant to deinstitutionalization was the epidemiological finding that 1 out of 8 men considered for military service for WWII were rejected based on neurological or psychiatric basis. These findings increased awareness that mental illness was moderately prevalent. More importantly, people began to realize the cost associated with admission to mental institutions (i.e. cost of lost productivity and mental health services).
This time period brought about change in the public and congressional attitudes toward the mentally ill. Since many individuals suffering from mental illness had served in the military, many began to think that more knowledge about mental illness and better services would not only benefit those that served but also national security as a whole. Moreover, Congress passed the National Mental Health Act of 1946, which created the National Institute of Mental Health
(NIMH). The NIMH was pivotal in funding essential health research for the developing mental health field.
During the 1950s many new drugs became available and incorporated into therapy for the mentally ill. These new drugs were effective in reducing severe symptoms, which could then allow people with mental illnesses to live in communities ranging from their own homes to half-way houses to nursing homes, etc. Drug therapy was not only quintessential for the depopulation of mental institutions, but it also opened opportunities for employment for the mentally ill.
In 1955, the Joint Commission on Mental Health and Health was authorised to investigate problems related to the mentally ill. President John F. Kennedy
had a special interest in the issue of mental health because his sister Rosemary
had been lobotomized at the age of 23 at request of her father because she left the convent she had been placed in. Shortly after his inauguration, Kennedy appointed a special "President's Panel of Mental Retardation". The panel included professionals and leaders of the organization. In 1962, the panel published a report with 112 recommendations to better serve the mentally ill. In conjunction with the Joint Commission on Mental Health and Health, The Presidential Panel of Mental Retardation, and Kennedy's influence, two important pieces of legislation were passed in 1963: The Maternal and Child Health and Mental Retardation Planning Amendments and the Mental Retardation Facilities and Community Mental Health Centers Act. The first piece of legislation increased funding for research that focused on prevention of retardation. The second piece of legislation provided funding for community facilities that serve people with mental disabilities. Both of these Acts furthered the process of deinstitutionalization.
In general, professionals, civil rights leaders, and humanitarians saw the shift from institutional confinement to local care as the appropriate approach. The Deinstitutionalization Movement started off slowly but gained momentum as it adopted philosophies from the Civil Rights Movement
. During the 1960s, deinstitutionalization increased dramatically as the average length of stay within mental institutions decreased by more than half. Many patients began to be placed in community care facilities instead of long term care institutions. Thus, the deinstitutionalization that took place in the United States has been considered by some to be more of a "transitionalisation", that is, a transition from a mental institution to a more human community centered facility.
Although public opinion of the mentally ill has increased, it is still often stigmatised. As a result, advocacy movements in support of mental health have emerged. These movements focus on reducing stigma and discrimination and increasing support groups and awareness. Another notable movement, the consumer or ex-patient movement
began as protests in the 1970s. Many of the participants consisted of ex-patients of mental institutions who felt the need to challenge the system's treatment of the mentally ill. Initially, this movement targeted issues surrounding involuntary commitment, use of electroconvulsive therapy (ECT), antipsychotic medication, and coercive psychiatry. The Liberation of Mental Patients, Project Release, and Insane Liberation Front were all examples of consumer movements and organisations. Many of these advocacy groups were successful in the judiciary system. The United States Court of Appeals for the First Circuit ruled in favor of the Mental Patient's Liberation Front in the case of Rogers vs. Okin. This ruling established the notion that patients had the right to refuse treatment. Another group, the National Alliance on Mental Illness
(NAMI), was very successful in its lobbying efforts to improve services and gain equality of insurance coverage for mental illnesses. President Bill Clinton signed the Mental Health Parity Act of 1996 allowing NAMI to reach its goal on the insurance coverage issue.
As hospitalisation costs increased, both the federal and state governments were motivated to find less expensive alternatives to hospitalisation. The 1965 amendments to Social Security shifted about 50 percent of the mental health care costs from state to the federal government. This motivated the government to promote deinstitutionalization.
A number of factors led to an increase in homelessness, including macroeconomic shifts, but observers also saw a change related to deinstitutionalization. Studies from the late 1980's indicated that one-third to one-half of homeless people had severe psychiatric disorders, often co-occurring with substance abuse
.
A process of indirect cost-shifting
may have led to a form of "re-institutionalisation" through the increased use of jail detention for those with mental disorders deemed unmanageable and noncompliant. When laws were enacted requiring communities to take more responsibility for mental health care, needed funding often was absent, therefore resulting in jail becoming the default option, with jails long documented as cheaper than psychiatric care. In Summer 2009, author and columnist Heather Mac Donald
stated in City Journal, "jails have become society's primary mental institutions, though few have the funding or expertise to carry out that role properly... at Rikers, 28 percent of the inmates require mental health services, a number that rises each year."
Related:
Psychiatric hospital
Psychiatric hospitals, also known as mental hospitals, are hospitals specializing in the treatment of serious mental disorders. Psychiatric hospitals vary widely in their size and grading. Some hospitals may specialise only in short-term or outpatient therapy for low-risk patients...
s with less isolated community mental health service
Community mental health service
Community mental health services , also known as Community Mental Health Teams in the United Kingdom, support or treat people with mental disorders in a domiciliary setting, instead of a psychiatric hospital . The array of community mental health services vary depending on the country in which...
for those diagnosed with a mental disorder or developmental disability
Developmental disability
Developmental disability is a term used in the United States and Canada to describe lifelong disabilities attributable to mental or physical impairments, manifested prior to age 18. It is not synonymous with "developmental delay" which is often a consequence of a temporary illness or trauma during...
. Deinstitutionalization can have multiple definitions; the first focuses on reducing the population size of mental institutions. This can be accomplished by releasing individuals from institutions, shortening the length of stays, and reducing both admissions and readmission. The second definition refers to reforming mental hospitals' institutional processes so as to reduce or eliminate reinforcement of dependency, hopelessness, learned helplessness, and other maladaptive behaviors.
According to psychiatrist and author Thomas Szasz (1920–present), deinstitutionalization is the policy and practice of transferring homeless, involuntarily hospitalised mental patients from state mental hospitals into many different kinds of de facto psychiatric institutions funded largely by the federal government. These federally subsidised institutions began in the United States and were quickly adopted by most Western governments. The plan was set in motion by the Community Mental Health Act
Community Mental Health Act
The Community Mental Health Act of 1963 was an act to provide federal funding for community mental health centers in the United States...
as a part of John F. Kennedy's legislature and passed by the US Congress in 1963, mandating the appointment of a commission to make recommendations for "combating mental illness in the United States" (Thomas Szasz, 'Coercion as Cure', p. 34).
In many cases the mass deinstitutionalization of the mentally ill in the Western world from the 1960s onward has translated into policies of "community release". Individuals who previously would have been in mental institutions are no longer supervised by health care workers. Some have considered deinstitutionalization to be a failure.
Origins
The 19th century saw a large expansion in the number and size of asylums in Western industrialised countries. Although initially based on principles of moral treatmentMoral treatment
Moral treatment was an approach to mental disorder based on humane psychosocial care or moral discipline that emerged in the 18th century and came to the fore for much of the 19th century, deriving partly from psychiatry or psychology and partly from religious or moral concerns...
, they became overstretched, non-therapeutic, isolated in location, and neglected in practice.
20th century
By the beginning of the 20th century, ever-increasing admissions had resulted in serious overcrowding causing many problems for the institutions. Funding was often cut, especially during periods of economic decline and wartime. Asylums became notorious for poor living conditions, lack of hygiene, overcrowding, ill-treatment, and abuse of patientsPatient abuse
Patient abuse or neglect is any action or failure to act which causes unreasonable suffering, misery or harm to the patient. It includes physically striking or sexually assaulting a patient. It also includes withholding of necessary food, physical care, and medical attention...
, many patients even starved to death.
The first community-based alternatives were suggested and tentatively implemented in the 1920s and 1930s, although asylum numbers continued to increase up to the 1950s. The movement for deinstitutionalization came to the forefront in various countries in the 1950s and 1960s.
The prevailing public arguments, time of onset, and pace of reforms varied by country. Class action lawsuits in the United States, and the scrutiny of institutions through disability activism and antipsychiatry, helped expose the poor conditions and treatment. Sociologists and others argued that such institutions maintained or created dependency, passivity, exclusion and disability, which caused people to become institutionalised.
There was an argument that community services would be cheaper, and it was suggested that new psychiatric medications made it more feasible to release people into the community.
A key text in the development of deinstitutionalization was Asylums
Asylums (book)
Asylums: Essays on the Social Situation of Mental Patients and Other Inmates is a book written by sociologist Erving Goffman in 1961. Asylums was a key text in the development of deinstitutionalisation. The book is one of the first sociological examinations of the social situation of mental...
by Erving Goffman
Erving Goffman
Erving Goffman was a Canadian-born sociologist and writer.The 73rd president of American Sociological Association, Goffman's greatest contribution to social theory is his study of symbolic interaction in the form of dramaturgical perspective that began with his 1959 book The Presentation of Self...
.
Unfortunately groups such as mental health professionals, public officials, families, advocacy groups, public citizens, and unions held differing views on deinstitutionalization.
Consequences
Community services that developed included supported housing with full or partial supervision, and specialised teams (such as assertive community treatmentAssertive Community Treatment
Assertive community treatment, or ACT, is an intensive and highly integrated approach for community mental health service delivery. ACT programs serve people whose symptoms of mental illness result in severe functional difficulties that interfere with their ability to achieve personally meaningful...
and early intervention teams
Early intervention in psychosis
Early intervention in psychosis is a clinical approach to those experiencing symptoms of psychosis for the first time. It forms part of a new prevention paradigm for psychiatry and is leading to reform of mental health services, especially in the United Kingdom....
) in the community. Costs have been reported to be as generally equivalent as inpatient hospitalisation, even lower in some cases (depending on how well or poorly funded community alternative are). Some regions introduced laws enabling forced medication in the community for those with psychiatric diagnoses.
Although deinstitutionalization has been positive for the majority of patients, it also has severe shortcomings.
Expectations that community care would lead to fuller social integration have not been achieved; many remain without work, have limited social contacts and often live in sheltered environments.
New community services were often uncoordinated and unable to meet complex needs. Services in the community sometimes isolated the mentally ill within a new ghetto
Ghetto
A ghetto is a section of a city predominantly occupied by a group who live there, especially because of social, economic, or legal issues.The term was originally used in Venice to describe the area where Jews were compelled to live. The term now refers to an overcrowded urban area often associated...
, where service users meet each other but have little contact with the rest of the public community. It has been said that instead of "community psychiatry", reforms established a "psychiatric community".
Existing patients were often discharged without sufficient preparation or support. A greater proportion of people with mental disorders became homeless or went to prison
Prison
A prison is a place in which people are physically confined and, usually, deprived of a range of personal freedoms. Imprisonment or incarceration is a legal penalty that may be imposed by the state for the commission of a crime...
. Widespread homelessness
Homelessness
Homelessness describes the condition of people without a regular dwelling. People who are homeless are unable or unwilling to acquire and maintain regular, safe, and adequate housing, or lack "fixed, regular, and adequate night-time residence." The legal definition of "homeless" varies from country...
occurred in some states in the USA and some other countries. Families can often play a crucial role in the care of those who would typically be placed in long-term treatment centers. However, many mentally ill people are resistant to such help due to the nature of their conditions. The majority of those who would be under continuous care in long-stay psychiatric hospitals are paranoid and delusional to the point that they refuse help and do not believe they need it, which makes it difficult to treat them.
Moves to community living and services led to various concerns and fears, from both the individuals themselves and other members of the community. Over a quarter of individuals accessing community mental health services in a US inner-city area are victims of at least one violent crime in a year, a proportion eleven times higher than the inner-city average.
The proportion is many times greater in every category of crime, including rape/sexual assault, other violent assaults, and personal and property theft. The rates are similar in those with developmental disabilities.
Despite perceptions by the public and media that people with mental disorders released into the community are more likely to be dangerous and violent, a large study indicated that they were no more likely to commit violence than those in the neighborhoods (usually economically deprived and high in substance abuse and crime) to which they typically lived.
Findings on violence committed by those with mental disorders in the community have been inconsistent and related to numerous factors; a higher rate of more serious offenses such as homicide have sometimes been found but, despite high-profile homicide cases, the evidence suggests this has not increased over the period of deinstitutionalization. The aggression and violence that does occur, in either direction, is usually within family settings rather than between strangers.
Asia
In JapanHealth in Japan
The high level of health in Japan is due to a number of factors including cultural habits, isolation, and an efficient universal health care system. Japan has one of the healthiest populations in the world according to many medical indicators...
, the number of hospital beds has risen steadily over the last few decades.
In Hong Kong
Health in Hong Kong
Hong Kong's medical infrastructure consists of a mixed medical economy, with 12 private hospitals and more than 50 public hospitals. There are also polyclinics that offer primary care services, including dentistry.-Overview:...
, a number of residential care services such as half-way house
Half-Way House
Half-Way House, also known as The Wiseburg Inn, is a historic inn and toll house located on York Road at Parkton, Baltimore County, Maryland. It is a large, -story Flemish bond brick structure. The main part, built as an inn about 1810, was placed in front of an earlier log structure which has...
s, long-stay care homes, supported hostel
Hostel
Hostels provide budget oriented, sociable accommodation where guests can rent a bed, usually a bunk bed, in a dormitory and share a bathroom, lounge and sometimes a kitchen. Rooms can be mixed or single-sex, although private rooms may also be available...
s are provided for the discharged patients. In addition, a number of community support services such as Community Rehabilitation Day Services, Community Mental Health Link, Community Mental Health Care, etc. have been launched to facilitate the patients to re-integrate into the community.
New Zealand
New ZealandNew Zealand
New Zealand is an island country in the south-western Pacific Ocean comprising two main landmasses and numerous smaller islands. The country is situated some east of Australia across the Tasman Sea, and roughly south of the Pacific island nations of New Caledonia, Fiji, and Tonga...
established a reconciliation
Truth and Reconciliation Commission
The Truth and Reconciliation Commission was a court-like restorative justice body assembled in South Africa after the abolition of apartheid. Witnesses who were identified as victims of gross human rights violations were invited to give statements about their experiences, and some were selected...
initiative in 2005 in the context of ongoing compensation
Damages
In law, damages is an award, typically of money, to be paid to a person as compensation for loss or injury; grammatically, it is a singular noun, not plural.- Compensatory damages :...
payouts to ex-patients of state-run mental institutions in the 1970s to 1990s. The forum heard of poor reasons for admissions; unsanitary and overcrowded conditions; lack of communication to patients and family members; physical violence and sexual misconduct and abuse; inadequate complaints mechanisms; pressures and difficulties for staff, within an authoritarian psychiatric hierarchy based on containment; fear and humiliation in the misuse of seclusion
Seclusion
The act of secluding, i.e. shutting out or keeping apart from society, or the state of being secluded, or a place that facilitates it . A person, a couple, or a larger group may go to a secluded place for privacy, or because the place is quiet...
; over-use and abuse of ECT
ECT
-Automotive:* Electronically controlled transmission, found in premium automobiles* Engine coolant temperature-Industry & Technology:* Eddy-current testing, a nondestructive testing technique for metal objects...
, psychiatric medication
Psychiatric medication
A psychiatric medication is a licensed psychoactive drug taken to exert an effect on the mental state and used to treat mental disorders. Usually prescribed in psychiatric settings, these medications are typically made of synthetic chemical compounds, although some are naturally occurring, or at...
and other treatments/punishments, including group therapy
Group therapy
Group psychotherapy or group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group...
, with continued adverse effects; lack of support on discharge; interrupted lives and lost potential; and continued stigma, prejudice and emotional distress and trauma.
There were some references to instances of helpful aspects or kindnesses despite the system. Participants were offered counseling to help them deal with their experiences, and advice on their rights, including access to records and legal redress.
Europe
Countries where deinstitutionalization has happened may be experiencing a process of "re-institutionalisation" or relocation to different institutions, as evidenced by increases in the number of supported housing facilities, forensic psychiatric beds and rising numbers in the prison population.Some developing European countries still rely on asylums.
Italy
Italy was the first country to start deinstitutionalization of mental health care and to develop a community-based psychiatric system. The Italian example originated samples of effective and innovative service models and paved the way for deinstitutionalization of mental patients. In 1978, the passing of Basaglia LawBasaglia Law
Basaglia Law is the Italian Mental Health Act of 1978 which signified a large reform of the psychiatric system in Italy, contained directives for the closing down of all psychiatric hospitals and led to their gradual replacement with a whole range of community-based services, including settings...
had started Italian psychiatric reform
Italian psychiatric reform
Psychiatric reform in Italy is the reform of psychiatry which started in Italy after the passing of Basaglia Law in 1978 and terminated with the very end of the Italian state mental hospital system in 1998.- Aims :...
that terminated with the very end of the Italian state mental hospital system in 1998. The reform was directed towards the gradual dismantling of the psychiatric hospitals and required a comprehensive, integrated and responsible community mental health service. The object of community care was to reverse the long-accepted practice of isolating the mental ill in large institutions, to promote their integration in the community offering them a milieu which is socially stimulating, while avoiding subjecting them to too intense social pressures.
United States
The United States has experienced two waves of deinstitutionalization. The first wave began in the 1950's and targeted people with mental illness. The second wave began roughly 15 years later and focused on individuals who had been diagnosed with a developmental disability (e.g. mental retardation). Although these waves began over 50 years ago, deinstitutionalization continues today. However, these waves are growing smaller as fewer people are sent to institutions.Numerous social forces have led to a move for deinstitutionalization. However, researchers generally speak of six main factors: criticisms of public mental hospitals, incorporation of mind-altering drugs in treatment, support from President Kennedy for federal policy changes in the treatment for those with mental illnesses, shifts to community based care, changes in public opinion of those with mental disabilities, and individual state's desire to reduce cost of mental hospitals.
Criticisms of public mental hospitals
The public's awareness of the conditions of mental institutions began to increase during World War II (WWII). During this period, conscientious objectors (COs) were assigned to alternative positions in which there were manpower shortages. Around 2,000 of them were assigned to fill job positions in understaffed mental institutions. In 1946, there was an expose in Life magazine detailing the shortfallings of many mental health facilities. This expose was be one of the first featured articles about the quality of mental institutions. Following WWII, articles and exposes about the mental hospital conditions would bombard popular and scholarly magazines and periodicals. In 1946, COs featured in the Life expose formed the National Mental Health Foundation, which was successful at convincing states to increase funding for mental institutions via public opinion support. 5 years later, the National Mental Health Foundation merged with the Hygiene and Psychiatric Foundation to form the National Association of Mental Health.
Another revelation during WWII relevant to deinstitutionalization was the epidemiological finding that 1 out of 8 men considered for military service for WWII were rejected based on neurological or psychiatric basis. These findings increased awareness that mental illness was moderately prevalent. More importantly, people began to realize the cost associated with admission to mental institutions (i.e. cost of lost productivity and mental health services).
This time period brought about change in the public and congressional attitudes toward the mentally ill. Since many individuals suffering from mental illness had served in the military, many began to think that more knowledge about mental illness and better services would not only benefit those that served but also national security as a whole. Moreover, Congress passed the National Mental Health Act of 1946, which created the National Institute of Mental Health
National Institute of Mental Health
The National Institute of Mental Health is one of 27 institutes and centers that make up the National Institutes of Health...
(NIMH). The NIMH was pivotal in funding essential health research for the developing mental health field.
The role of pharmacotherapy and deinstitutionalization
During the 1950s many new drugs became available and incorporated into therapy for the mentally ill. These new drugs were effective in reducing severe symptoms, which could then allow people with mental illnesses to live in communities ranging from their own homes to half-way houses to nursing homes, etc. Drug therapy was not only quintessential for the depopulation of mental institutions, but it also opened opportunities for employment for the mentally ill.
President Kennedy's Support of Policy Change
In 1955, the Joint Commission on Mental Health and Health was authorised to investigate problems related to the mentally ill. President John F. Kennedy
John F. Kennedy
John Fitzgerald "Jack" Kennedy , often referred to by his initials JFK, was the 35th President of the United States, serving from 1961 until his assassination in 1963....
had a special interest in the issue of mental health because his sister Rosemary
Rosemary Kennedy
Rose Marie "Rosemary" Kennedy was the third child and first daughter of Rose Elizabeth Kennedy née Fitzgerald and Joseph Patrick Kennedy, Sr., born little more than a year after her brother, future U.S. President John F. Kennedy...
had been lobotomized at the age of 23 at request of her father because she left the convent she had been placed in. Shortly after his inauguration, Kennedy appointed a special "President's Panel of Mental Retardation". The panel included professionals and leaders of the organization. In 1962, the panel published a report with 112 recommendations to better serve the mentally ill. In conjunction with the Joint Commission on Mental Health and Health, The Presidential Panel of Mental Retardation, and Kennedy's influence, two important pieces of legislation were passed in 1963: The Maternal and Child Health and Mental Retardation Planning Amendments and the Mental Retardation Facilities and Community Mental Health Centers Act. The first piece of legislation increased funding for research that focused on prevention of retardation. The second piece of legislation provided funding for community facilities that serve people with mental disabilities. Both of these Acts furthered the process of deinstitutionalization.
The shift to community based mental health care
In general, professionals, civil rights leaders, and humanitarians saw the shift from institutional confinement to local care as the appropriate approach. The Deinstitutionalization Movement started off slowly but gained momentum as it adopted philosophies from the Civil Rights Movement
Civil rights movement
The civil rights movement was a worldwide political movement for equality before the law occurring between approximately 1950 and 1980. In many situations it took the form of campaigns of civil resistance aimed at achieving change by nonviolent forms of resistance. In some situations it was...
. During the 1960s, deinstitutionalization increased dramatically as the average length of stay within mental institutions decreased by more than half. Many patients began to be placed in community care facilities instead of long term care institutions. Thus, the deinstitutionalization that took place in the United States has been considered by some to be more of a "transitionalisation", that is, a transition from a mental institution to a more human community centered facility.
Changing public opinion of the mentally ill
Although public opinion of the mentally ill has increased, it is still often stigmatised. As a result, advocacy movements in support of mental health have emerged. These movements focus on reducing stigma and discrimination and increasing support groups and awareness. Another notable movement, the consumer or ex-patient movement
Psychiatric survivors movement
The psychiatric survivors movement is a diverse association of individuals who are either currently clients of mental health services , or who consider themselves survivors of interventions by psychiatry, or who identify themselves as ex-patients of mental health services...
began as protests in the 1970s. Many of the participants consisted of ex-patients of mental institutions who felt the need to challenge the system's treatment of the mentally ill. Initially, this movement targeted issues surrounding involuntary commitment, use of electroconvulsive therapy (ECT), antipsychotic medication, and coercive psychiatry. The Liberation of Mental Patients, Project Release, and Insane Liberation Front were all examples of consumer movements and organisations. Many of these advocacy groups were successful in the judiciary system. The United States Court of Appeals for the First Circuit ruled in favor of the Mental Patient's Liberation Front in the case of Rogers vs. Okin. This ruling established the notion that patients had the right to refuse treatment. Another group, the National Alliance on Mental Illness
National Alliance on Mental Illness
The National Alliance on Mental Illness was founded in 1979 as the National Alliance for the Mentally Ill. NAMI is a nation-wide American advocacy group, representing families and people affected by mental illness as a non-profit grass roots organization and has affiliates in every American state...
(NAMI), was very successful in its lobbying efforts to improve services and gain equality of insurance coverage for mental illnesses. President Bill Clinton signed the Mental Health Parity Act of 1996 allowing NAMI to reach its goal on the insurance coverage issue.
Government's desire to reduce cost and spending on hospitalisation
As hospitalisation costs increased, both the federal and state governments were motivated to find less expensive alternatives to hospitalisation. The 1965 amendments to Social Security shifted about 50 percent of the mental health care costs from state to the federal government. This motivated the government to promote deinstitutionalization.
A number of factors led to an increase in homelessness, including macroeconomic shifts, but observers also saw a change related to deinstitutionalization. Studies from the late 1980's indicated that one-third to one-half of homeless people had severe psychiatric disorders, often co-occurring with substance abuse
Substance abuse
A substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...
.
A process of indirect cost-shifting
Cost-shifting
Cost-shifting is either an economic situation where one group underpays for a service resulting another group overpaying for a service or where one group pays a smaller share of costs than before resulting in another group paying a larger share of costs than before...
may have led to a form of "re-institutionalisation" through the increased use of jail detention for those with mental disorders deemed unmanageable and noncompliant. When laws were enacted requiring communities to take more responsibility for mental health care, needed funding often was absent, therefore resulting in jail becoming the default option, with jails long documented as cheaper than psychiatric care. In Summer 2009, author and columnist Heather Mac Donald
Heather Mac Donald
Heather Lynn Mac Donald is an American political commentator and thinker notable for her advocacy of secular conservatism. She has advocated her positions on numerous subjects including crime prevention, immigration reform, academia, the art world, and politics. She is a prolific essayist...
stated in City Journal, "jails have become society's primary mental institutions, though few have the funding or expertise to carry out that role properly... at Rikers, 28 percent of the inmates require mental health services, a number that rises each year."
South America
In several South American countries, the total number of beds in asylum-type institutions has decreased, replaced by psychiatric inpatient units in general hospitals and other local settings.See also
- Care programme approachCare programme approachCare Programme Approach is a United Kingdom system of delivering community services to those with mental illness. It was introduced to England in 1991 and by 1996 become a key component of the mental health system in England...
- Institutional syndrome
- Public housingPublic housingPublic housing is a form of housing tenure in which the property is owned by a government authority, which may be central or local. Social housing is an umbrella term referring to rental housing which may be owned and managed by the state, by non-profit organizations, or by a combination of the...
- Mental healthMental healthMental health describes either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism mental health may include an individual's ability to enjoy life and procure a balance between life activities and...
- Care in the CommunityCare in the CommunityCare in the Community is the British policy of deinstitutionalization, treating and caring for physically and mentally disabled people in their homes rather than in an institution...
- Italian psychiatric reformItalian psychiatric reformPsychiatric reform in Italy is the reform of psychiatry which started in Italy after the passing of Basaglia Law in 1978 and terminated with the very end of the Italian state mental hospital system in 1998.- Aims :...
- Franco BasagliaFranco BasagliaFranco Basaglia was an Italian psychiatrist and neurologist, professor who proposed the dismantling of psychiatric hospitals, pioneer of the modern concept of mental health, Italian psychiatry reformer, charismatic leader in Italian psychiatry, figurehead and founder of Democratic...
Related:
- HomelessnessHomelessnessHomelessness describes the condition of people without a regular dwelling. People who are homeless are unable or unwilling to acquire and maintain regular, safe, and adequate housing, or lack "fixed, regular, and adequate night-time residence." The legal definition of "homeless" varies from country...
- Skid rowSkid rowA skid row or skid road is a run-down or dilapidated urban area with a large, impoverished population. The term originally referred literally to a path along which working men skidded logs. Its current sense appears to have originated in the Pacific Northwest...
- Homeless dumpingHomeless dumpingHomeless dumping is the practice of hospital employees or emergency workers releasing homeless patients on the streets instead of placing them into the custody of a relative, a warming center or shelter or retaining them in a hospital where they may require expensive medical care...
Further reading
}}- Stavis, Paul F., "Homeward Bound: The Developing Legal Right to a Home in the Community", Quality of Care Newsletter, Issue 48, April–May 1991, New York State Commission on Quality of Care and Advocacy for Persons with Disabilities.