Deinstitutionalisation

This article is about the replacement of psychiatric hospitals. For the replacement of orphanages, see Deinstitutionalization (orphanages and children's institutions).

Deinstitutionalization or deinstitutionalization is the process of replacing long-stay psychiatric hospitals 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.^[1] 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.^[1]

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.^[2]

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 treatment, they became overstretched, non-therapeutic, isolated in location, and neglected in practice.^[3]

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 patients, many patients even starved to death.^[4]

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.^[4] 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.^[5]

A key text in the development of deinstitutionalization was Asylums by Erving Goffman.^[6]

Unfortunately groups such as mental health professionals, public officials, families, advocacy groups, public citizens, and unions held differing views on deinstitutionalization.^[7]

Consequences

Community services that developed included supported housing with full or partial supervision, and specialised teams (such as assertive community treatment 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).^[4] 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.^[8]

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".^[4]

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.^[4] 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.^[9]

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.^[10][11]

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.^[12]

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.^[13][14][15] The aggression and violence that does occur, in either direction, is usually within family settings rather than between strangers.^[16]

Deinstitutionalization and the status of psychiatric institutions around the world

Asia

In Japan, the number of hospital beds has risen steadily over the last few decades.^[4]

In Hong Kong, a number of residential care services such as half-way houses, long-stay care homes, supported hostels 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 Zealand 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.^[17]

Africa

Uganda has one psychiatric hospital.^[4]

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.^[18]

Some developing European countries^[specify] 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.^[19] The Italian example originated samples of effective and innovative service models and paved the way for deinstitutionalization of mental patients.^[19] In 1978, the passing of Basaglia Law had started Italian psychiatric reform that terminated with the very end of the Italian state mental hospital system in 1998.^[20] The reform was directed towards the gradual dismantling of the psychiatric hospitals and required a comprehensive, integrated and responsible community mental health service.^[21]:665 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.^[21]:664

United Kingdom

See Care in the Community.

North America

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.^[1] The second wave began roughly 15 years later and focused on individuals who had been diagnosed with a developmental disability (e.g. mental retardation).^[1] 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.^[1]

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.^[1] Around 2,000 of them were assigned to fill job positions in understaffed mental institutions.^[1] In 1946, there was an expose in Life magazine detailing the shortfallings of many mental health facilities.^[1] 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.^[1] 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.^[1] 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).^[1]

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.^[1] 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.^[1]

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.^[1] Drug therapy was not only quintessential for the depopulation of mental institutions, but it also opened opportunities for employment for the mentally ill.^[1]

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 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.^[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. 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.^[1] 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.^[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 as 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] 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.^[1]

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.^[1] 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.^[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 (ECT), antipsychotic medication, and coercive psychiatry.^[1] 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.^[1] 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.^[1] 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.^[1] The 1965 amendments to Social Security shifted about 50 percent of the mental health care costs from state to the federal government.^[1] 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.^[22][23][24] 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.^[25][26]

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.^[27][28] 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,^[29] with jails long documented as cheaper than psychiatric care.^[27] 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."^[30]

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.^[4]

See also

• Care programme approach
• Institutional syndrome
• Public housing
• Mental health
• Care in the Community
• Italian psychiatric reform
• Franco Basaglia

Related:

• Homelessness
• Skid row
• Homeless dumping

References

1. ^ ^{a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae} Stroman, Duane. 2003. The Disability Rights Movement: From Deinstitutionalization to Self-determination. University Press of America.
2. ^ Documenting the Failure of Deinstitutionalization by E. Fuller Torrey, MD
3. ^ Wright D (April 1997). "Getting out of the asylum: understanding the confinement of the insane in the nineteenth century". Soc Hist Med 10 (1): 137–55. doi:10.1093/shm/10.1.137. PMID 11619188. 
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9. ^ The Insanity Offense: How America’s Failure to Treat the Seriously Mentally Ill Endangers Its Citizens, E. Fuller Torey © 2008 ISBN 978-0-393-06658-6
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11. ^ Petersilia JR (2001). "Crime Victims With Developmental Disabilities: A Review Essay". Criminal Justice and Behavior 28 (6): 655–94. doi:10.1177/009385480102800601. http://cjb.sagepub.com/cgi/content/abstract/28/6/655. 
12. ^ Steadman HJ, Mulvey EP, Monahan J, et al. (May 1998). "Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods". Arch. Gen. Psychiatry 55 (5): 393–401. doi:10.1001/archpsyc.55.5.393. PMID 9596041. http://archpsyc.ama-assn.org/cgi/pmidlookup?view=long&pmid=9596041. 
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14. ^ Stuart H (June 2003). "Violence and mental illness: an overview". World Psychiatry 2 (2): 121–4. PMC 1525086. PMID 16946914. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1525086. 
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23. ^ Rubin, Lillian B., "Sand Castles and Snake Pits: Homelessness, Public Policy, and the Law of Unintended Consequences", Dissent journal, Fall 2007.
24. ^ Friedman, Michael B., "Keeping The Promise of Community Mental Health", The Journal News, August 8, 2003
25. ^ McQuistion HL, Finnerty M, Hirschowitz J, Susser ES (May 2003). "Challenges for psychiatry in serving homeless people with psychiatric disorders". Psychiatr Serv 54 (5): 669–76. doi:10.1176/appi.ps.54.5.669. PMID 12719496. http://ps.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=12719496. 
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27. ^ ^{a b} 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. http://books.google.com/?id=kR_t_xV5RJIC&printsec=frontcover&dq=%22criminalizing+the+seriously+mentally+ill%22#v=onepage&q&f=false. Retrieved 12 November 2010 
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Bibliography

• Borus JF (August 1981). "Sounding Board. Deinstitutionalization of the chronically mentally ill". N. Engl. J. Med. 305 (6): 339–42. doi:10.1056/NEJM198108063050609. PMID 7242636. 
• Pepper B, Ryglewicz H (1985). "The role of the state hospital: a new mandate for a new era". Psychiatr Q 57 (3–4): 230–57. doi:10.1007/BF01277617. PMID 3842522. 
• Sharfstein SS (August 1979). "Community mental health centers: returning to basics". Am J Psychiatry 136 (8): 1077–9. PMID 464136. http://ajp.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=464136. 
• E. Fuller Torrey and Mary Zdanowicz (August 4, 1998). Why deinstitutionalization turned deadly. Wall Street Journal
• Deinstitutionalization of Persons with Developmental Disabilities: A Technical Assistance Report for Legislators.
• Deinstitutionalization: A Psychiatric 'Titanic'. PBS Frontline
• Torrey, E. Fuller (1997). Out of the shadows: confronting America's mental illness crisis. New York: John Wiley. ISBN 0-471-16161-6. 

Further reading

• Arce AA, Vergare MJ (December 1987). "Homelessness, the chronic mentally ill and community mental health centers". Community Ment Health J 23 (4): 242–9. PMID 3440376. 
• Institute of Medicine (US) Committee on Health Care for Homeless People (1988). Homelessness, Health, and Human Needs. Washington, D.C: National Academy Press. p. 97. ISBN 0-309-03832-4. 
• Kramer M (1969). "Statistics of Mental Disorders in the United States: Current Status, Some Urgent Needs and Suggested Solutions". Journal of the Royal Statistical Society. Series A (General) 132 (3): 353–407. doi:10.2307/2344118. JSTOR 2344118. 
• Lamb, H. Richard; Weinberger, Linda E (April 1998). "Persons With Severe Mental Illness in Jails and Prisons: A Review". Psychiatric Services 49 (4): 483–492. PMID 9550238. http://psychservices.psychiatryonline.org/cgi/content/full/49/4/483. Retrieved 13 November 2010 
• Rochefort, David A. (1993). From Poorhouses to Homelessness: Policy Analysis and Mental Health Care. Westport, Conn: Auburn House. ISBN 0-86569-237-8. 
• Rudin E, McInnes RS (July 1963). "COMMUNITY MENTAL HEALTH SERVICES ACT—Five Years of Operation Under the California Law". Calif Med 99 (1): 9–11. PMC 1515154. PMID 13982995. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1515154. 
• Sharfstein SS (May 2000). "Whatever happened to community mental health?". Psychiatr Serv (American Psychiatric Association) 51 (5): 616–20. doi:10.1176/appi.ps.51.5.616. PMID 10783179. http://psychservices.psychiatryonline.org/cgi/content/full/51/5/616. 
• 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.
• Apollonio DE, Malone RE (December 2005). "Marketing to the marginalised: tobacco industry targeting of the homeless and mentally ill". Tob Control 14 (6): 409–15. doi:10.1136/tc.2005.011890. PMC 1748120. PMID 16319365. http://tobaccocontrol.bmj.com/cgi/pmidlookup?view=long&pmid=16319365.