Deinstitutionalization in the United States

The United States has experienced two waves of deinstitutionalization, the process of replacing long-stay psychiatric hospitals with less isolated community mental health services for those diagnosed with a mental disorder or developmental disability.

The first wave began in the 1950s and targeted people with mental illness.[1] The second wave began roughly 15 years later and focused on individuals who had been diagnosed with a developmental disability.[1] Deinstitutionalization continues today, though the movements are growing smaller as fewer people are sent to institutions.

Numerous social forces led to a move for deinstitutionalization; researchers generally give credit to six main factors: criticisms of public mental hospitals, incorporation of mind-altering drugs in treatment, support from President Kennedy for federal policy changes, shifts to community-based care, changes in public perception, and individual states' desires to reduce costs from mental hospitals.[1]

Criticisms of public mental hospitals

The public's awareness of conditions in mental institutions began to increase during World War II. Conscientious objectors (COs) of the war were assigned to alternative positions which suffered from manpower shortages.[1] Around 2,000 COs were assigned to work in understaffed mental institutions.[1] In 1946, an exposé in Life magazine detailed the shortfalls of many mental health facilities.[1] This exposé was one of the first featured articles about the quality of mental institutions.[1]

Following WWII, articles and exposés about the mental hospital conditions bombarded popular and scholarly magazines and periodicals. The COs from the 1946 Life exposé formed the National Mental Health Foundation, which raised public support and successfully convinced states to increase funding for mental institutions.[1] Five years later, the National Mental Health Foundation merged with the Hygiene and Psychiatric Foundation to form the National Association of Mental Health.

During WWII, it was found that 1 out of 8 men considered for military service was rejected based on a neurological or psychiatric problem.[1] This increased awareness of the prevalence of mental illnesses, and people began to realize the costs associated with admission to mental institutions (i.e. cost of lost productivity and of mental health services).[1]

Since numerous individuals suffering from mental illness had served in the military, many began to believe that more knowledge about mental illness and better services would not only benefit those who served but also national security as a whole.[1] Congress passed the National Mental Health Act of 1946, which created the National Institute of Mental Health (NIMH). NIMH was pivotal in funding research for the developing mental health field.[1]

In New York ARC v. Rockefeller, parents of 5,000 residents at the Willowbrook State School in Staten Island, New York, filed suit over the inhumane living conditions at that institution, where residents were abused and neglected. A 1972 television broadcast from the Willowbrook State School, titled "Willowbrook: The Last Great Disgrace," outraged the general public. However, it took 3 years from the time the lawsuit documents were filed before the consent judgement was signed. In 1975, the consent judgement was signed, and it committed New York state to improve community placement for the now designated "Willowbrook Class." The Willowbrook State School was closed in 1987, and all but about 150 of the former Willowbrook residents were moved to group homes by 1992.[2][3][4][5][6]

In 1973, a federal district court ruled in Souder v. Brennan that patients in mental health institutions must be considered employees and paid the minimum wage required by the Fair Labor Standards Act of 1938 whenever they performed any activity that conferred an economic benefit on an institution. Following this ruling, institutional peonage was outlawed, as evidenced in Pennsylvania's Institutional Peonage Abolishment Act of 1973.

Rosenhan's experiment in 1973 "accelerated the movement to reform mental institutions and to deinstitutionalize as many mental patients as possible."[7]

Pharmacotherapy

During the 1950s, new drugs became available and were incorporated into treatment for the mentally ill. The new drugs effectively reduced severe symptoms, allowing the mentally ill to live in environments less stringent than institutions, such as halfway houses, nursing homes, or their own homes. Drug therapy also allowed many mentally ill to obtain employment.[1]

President Kennedy

In 1955, the Joint Commission on Mental Health and Health was authorized 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 the request of her father.[1] Shortly after his inauguration, Kennedy appointed a special President's Panel of Mental Retardation.[1] 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.[1]

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, which increased funding for research on the prevention of retardation, and the Mental Retardation Facilities and Community Mental Health Centers Construction Act, which provided funding for community facilities that served people with mental disabilities.[1] Both acts furthered the process of deinstitutionalization.

Shift to community-based care

In general, professionals, civil rights leaders, and humanitarians saw the shift from institutional confinement to local care as the appropriate approach.[1] The deinstitutionalization movement started off slowly but gained momentum as it adopted philosophies from the Civil Rights Movement.[1] During the 1960s, deinstitutionalization increased dramatically, and the average length of stay within mental institutions decreased by more than half.[1] Many patients began to be placed in community care facilities instead of long-term care institutions.[1]

Changing public opinion

While public opinion of the mentally ill has improved somewhat, it is still often stigmatized. Advocacy movements in support of mental health have emerged.[1] These movements focus on reducing stigma and discrimination and increasing support groups and awareness. The consumer or ex-patient movement, began as protests in the 1970s, forming groups such as Liberation of Mental Patients, Project Release, Insane Liberation Front, and the National Alliance on Mental Illness (NAMI).[1]

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.[1] Initially, this movement targeted issues surrounding involuntary commitment, use of electroconvulsive therapy, anti-psychotic medication, and coercive psychiatry.[1] Many of these advocacy groups were successful in the judiciary system. In 1975, the United States Court of Appeals for the First Circuit ruled in favour of the Mental Patient's Liberation Front of Rogers v. Okin,[1] establishing the right of a patient to refuse treatment.

A 1975 award-winning film, One Flew Over the Cuckoo's Nest, sent a message regarding the rights of those committed involuntarily. That same year, the U.S. Supreme Court restricted the rights of states to incarcerate someone who was not violent. This was followed up with a 1978 ruling further restricting states from confining anyone involuntarily for mental illness.

NAMI successfully lobbied to improve mental health services and gain equality of insurance coverage for mental illnesses.[1] In 1996, the Mental Health Parity Act was enacted into law, realizing the mental health movement's goal of equal insurance coverage.

In 1955 for every 100,000 US citizens there was 340 psychiatric hospital beds. In 2005 that number had diminished to 17 per 100,000.

Reducing costs

As hospitalization costs increased, both the federal and state governments were motivated to find less expensive alternatives to hospitalization.[1] The 1965 amendments to Social Security shifted about 50% of the mental health care costs from states to the federal government,[1] motivating the government to promote deinstitutionalization.

The increase in homelessness was seen as related to deinstitutionalization.[8][9][10] Studies from the late 1980s indicated that one-third to one-half of homeless people had severe psychiatric disorders, often co-occurring with substance abuse.[11][12]

A process of indirect cost-shifting may have led to a form of "re-institutionalization" through the increased use of jail detention for those with mental disorders deemed unmanageable and noncompliant.[13][14] When laws were enacted requiring communities to take more responsibility for mental health care, necessary funding was often absent, and jail became the default option,[15] being cheaper than psychiatric care.[13]

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."[16]

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Stroman, Duane (2003). The Disability Rights Movement: From Deinstitutionalization to Self-determination. University Press of America.
  2. ↑ "Disability History Timeline". Rehabilitation Research & Training Center on Independent Living Management. Temple University. 2002.
  3. ↑ "Sproutflix website description of film titled Willowbrook: The Last Great Disgrace". Retrieved 6 October 2014.
  4. ↑ New York Times article, "Big Day for Ex-Residents Of Center for the Retarded," by Celia W. Duggar, published March 12, 1993
  5. ↑ NYS Office For People With Developmental Disabilities, article title Milestones in OMRDD's History
  6. ↑ Museum of DisABILITY History, article title The New York State Timeline
  7. ↑ Kornblum, William (2011). Mitchell, Erin; Jucha, Robert; Chell, John, eds. Sociology in a Changing World (9th ed.). Cengage learning. p. 195. ISBN 978-1-111-30157-6.
  8. ↑ Scanlon, John (2 October 1989). "Homelessness: Describing the Symptoms, Prescribing a Cure". Backgrounder. Heritage Foundation. 729.
  9. ↑ Rubin, Lillian B. (Fall 2007). "Sand Castles and Snake Pits: Homelessness, Public Policy, and the Law of Unintended Consequences". Dissent. Archived from the original on July 18, 2009.
  10. ↑ Friedman, Michael B. (8 August 2003). "Keeping The Promise of Community Mental Health". The Journal News. Archived from the original on September 27, 2007.
  11. ↑ McQuistion, Hunter L.; Finnerty, Molly; Hirschowitz, Jack; Susser, Ezra S. (May 2003). "Challenges for psychiatry in serving homeless people with psychiatric disorders". Psychiatric Services. 54 (5): 669–76. doi:10.1176/appi.ps.54.5.669. PMID 12719496.
  12. ↑ Feldman, S. (June 1983). "Out of the hospital, onto the streets: the overselling of benevolence". Hastings Center Report. 13 (3): 5–7. doi:10.2307/3561609. JSTOR 3561609. PMID 6885404.
  13. 1 2 Torrey, E. Fuller; Stieber, Joan; Ezekiel, Jonathan; Wolfe, Sidney M.; Sharfstein, Joshua; Noble, John H.; Flynn, Laurie M. (1992). Criminalizing the Seriously Mentally Ill: The Abuse of Jails as Mental Hospitals. A joint report of the National Alliance for the Mentally Ill and Public Citizen's Health Research Group. ISBN 0-7881-4279-8. Retrieved 12 November 2010.
  14. ↑ Domino, Marisa Elena; Norton, Edward C.; Morrissey, Joseph P.; Thakur, Neil (October 2004). "Cost Shifting to Jails after a Change to Managed Mental Health Care". Health Serv Res. 39 (5): 1379–401. doi:10.1111/j.1475-6773.2004.00295.x. PMC 1361075Freely accessible. PMID 15333114.
  15. ↑ Roche, Timothy (10 July 2000). "The Chief and His Ward". Time Magazine. Retrieved 12 November 2010.
  16. ↑ Mac Donald, Heather. "The Jail Inferno". City Journal. Retrieved 27 July 2009.
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