June 2, 2014
The Deinstitutionalization Movement and its
Long Term Effects on Society
Deinstitutionalization is the process of replacing long-stay psychiatric hospitals with less isolated community mental health services for people diagnosed with a mental disorder or developmental disability. Deinstitutionalization has been an overall benefit for most psychiatric patients, but many have been left homeless and without care. Another result is the increase of people in prisons and county jails who have a severe mental illness. Without the proper treatment these people, who are sometimes undiagnosed, can develop drug addiction and substance abuse dependency and become threats to themselves as well as other people within the community. Deinstitutionalization began after a few major changes. First was the widespread introduction of chlorpromazine, commonly known as Thorazine, the first effective antipsychotic medication, in 1955. The antipsychotic Thorazine helped to mange the onset of psychotic episodes. Second was a liberal shift in people’s views advocating for the stricter legal standards for involuntary commitment. Then in 1963 President John F. Kennedy signed the Mental Retardation Facilities and Community Mental Health Centers Construction Act (CMCHA) to create community- based mental health facilities (Amadeo, 2013). The National Institute of Mental Health created them to provide prevention, early treatment, and ongoing care, allowing patients to be closer to families and integrated in society. A major shift in funding happened in 1965. Medicaid was passed and it did not pay for patients to stay in mental hospitals, the Federal government now covered the expense of patients who were being transferred to nursing homes and hospitals. There were 558,239 severely mentally ill patients in the nation’s public psychiatric hospitals in 1955. The nation’s population at the time was 164 million. If those numbers were compared to today’s population of 260 million, there would have been 885,010 patients. By 1992, this number had been reduced to 71,619. Approximately 92% of the people living in these facilities in 1955 were not living there in 1994 (Torrey, 1997). Massachusetts, New Hampshire, Vermont, West Virginia, Arkansas, Wisconsin, and California had the highest effective deinstitutionalization rates of over 95%. Rhode Island’s rate is over 98%. That means that for every hundred state residents in psychiatric hospitals in 1955, less than two patients are there today. A majority of the people who were deinstitutionalized were severely mentally ill. About 50-60% of them were diagnosed with schizophrenia, 10-15% was diagnosed with a manic-depressive illness and severe depression, and an additional 10-15% was diagnosed with an organic brain disease, ex. Epilepsy, strokes, Alzheimer’s disease, and brain damage secondary to trauma. The remaining individuals residing in public psychiatric hospitals had conditions such as mental retardation with psychosis, autism, and other psychiatric disorders of childhood, and alcoholism and drug addiction with concurrent brain damage (Torrey, 1997). What deinstitutionalization has done is create a mental illness crisis, by discharging people from public psychiatric hospitals without ensuring that they are receiving the medication and rehabilitation services necessary for them to live successfully in the community. Once the psychiatric beds were closed, they were no longer available for people who later became mentally ill, and this is a present situation. Consequently, approximately 2.2 million people who are severely mentally ill do not receive any psychiatric treatment. The benefits of deinstitutionalization have been identified as independence and a better quality of life outside of the institutions, a reduction in psychotropic medication needs, and increased socialization and adaptability to change. The individuals who were affected the most by deinstitutionalization were the homeless. Some of these individuals have found it extremely difficult to sustain themselves in the community and now outside the facilities there is easier access to alcohol and other chemical substances. These individuals were often isolated and victimized. Some of these individuals who were homeless and who had a severe mental illness often deteriorated and were sometimes reinstitutionalized, and some lost their lives. The community is often afraid of people with mental illness believing these people are dangerous. This belief often caused rejection, stigmatization, victimization, and harassment. These people often only receive fragmented treatment, but most significantly is the inadequate housing opportunities. The mentally ill patients who became homeless now become unsupported and at a high risk for self harm. In a recent study, it was concluded that individuals with a severe mental illness were victims of a violent crime at a rate of 11 times higher than that of the general population (Kliewer, Mcnally, Trippany, 2009). “Deinstitutionalization doesn’t work. We just switched places. Instead of being in hospitals the people are in jail. The whole system is topsy-turvy and the last person served is the mentally ill person.”—Jail official, Ohio In the state and federal prisons populations, as well as county jails, roughly 15-22% of individuals incarcerated have psychotic disorders, compared to 3.1% of the general population. In as much as 66% of these cases, these individuals have served prior sentences. Only one in three of these inmates report receiving mental health treatment while incarcerated. These individuals are twice as likely to be homeless when not incarcerated (Kliewer, Mcnally, Trippany, 2009). In 1973 a study in Santa Clara County, California, indicated the jail population had risen 300 percent in the four years after the close of Agnes State Psychiatric Hospital, located in the same county. In 1975, a study of five California jails by Arthur Bolton and Associates reported that the number of severely mentally ill prisoners had grown 300 percent over ten years. It is apparent that jails and prisons have become the surrogate mental hospitals for many people with a severe mental illness. The first positive change in favor of those suffering from a severe mental illness was the Patient Protection and Affordable Care Act, signed into law in early 2010. This is the first substantial government expansion and restoration of healthcare system since the Medicaid and Medicare was passed in the mid 60’s. The rate of uninsured people in the US is expected to be cut in half, and the poorest of the population, particularly people who are homeless are expected to benefit. As this new health care becomes more accessible to individuals living in poverty and those on the brink of homelessness or living in jails and prisons, we will hopefully see an increase in mainstream services. Programs like The Health Resources and Services Administration (HCH) who go out into the community reaching out to people who are homeless and providing services. The HCH staff will go out to abandoned buildings, under bridges, street benches parks, and encampments, in search of homeless people who have severe mental illnesses to treat them. With two decades of deinstitutionalization it is clear that two things are needed. First, is funding and coordination for a vast expansion of community housing and other services. Secondly there needs to be some realization that community services don’t always meet the needs of the severely mentally ill. There also needs to be better treatment for those who are institutionalized in prisons and jails. Another key solution is long term treatment, this needs to be provided to ensure a overall stable mental health status. But not only do we need to provide them with healthcare and treatment, but also with housing and other things associated with the daily living needs that all people require. Paul A. Dever State School for people with developmental disabilities. Most of the facility was closed by 1991, but the entire place was closed in 2002.
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Kliewer, S. P. McNally, M. Trippany, R. L. (2009). Deinstitutionalization: It’s Impact on Community Mental Health Centers and the Seriously Mentally Ill. The Alabama Counseling Association Journal. 35. 1. 40-45
Krieg, R. G. (200)1. An Interdisciplinary Look at the Deinstitutionalization of the Mentally Ill. The Social Science Journal. 38. 367-380 Torrey, E. F. M.D. (1997). Out of the Shadows: Confronting America’s Mental Illness Crisis. New York: John Wiley and Sons.
Wolfe, P. B. Zerger, S. Zlotnick, C. (2013). Healthcare for the Homeless: What We Have Learned in the Past 30 Years and What’s Next. American Journal of Public Health. 103. S2. S199-S205