Deinstitutionalization

By the time the antipsychiatry critique appeared, the Great Confinement already had begun to wane. Beginning in 1955, the number of mental hospital inmates declined steadily as treatment shifted from inpatient care (in hospitals) to outpa- tient care. This process of moving mental health care away from large institutions, known as deinstitutionalization, gained further support during the 1970s as mental patients successfully fought in the courts against involuntary treatment, against hospitals that provided custodial care rather than therapy, and for the right to treatment in the “least restrictive setting” appropriate for their care.

Those who adopt a medical model of illness typically assume that deinstitu- tionalization resulted from the introduction, beginning in 1954, of various drugs that were believed to reduce severe psychiatric symptoms. Yet the number of pa- tients in public mental hospitals did not fall rapidly until more than a decade after these drugs were introduced. In fact, the sharp decline in institutionalization is better explained by changes in federal funding that enabled some chronically mentally ill persons to live on their own while encouraging nursing homes and private hospitals to seek other chronically mentally ill persons as residents—paid for by the federal government.

Unfortunately, the promise that deinstitutionalization would herald a new era in which individuals would receive appropriate therapy in the community and avoid the stigma, degradation, and mortification of mental hospitalization has been met only partially. Few services are available outside of psychiatric hospitals to help individuals who have serious mental illnesses.

Meanwhile, as government funding for the nation’s health care system de- clined, funding for the criminal justice system dramatically increased (Human Rights Watch, 2009). As a result, public mental hospitals now find that they can most easily pay their bills by accepting patients sent to them by the criminal justice system, whether mentally ill prison inmates, people found innocent by reason of insanity, or “sex predators,” who under recent laws can be involuntarily confined even after finishing their sentences. These changes reflect the continuing stigma of mental illness. “Ethical Debate: Mental Illness and Gun Control,” further illustrates the consequences of that stigma.

Simultaneously with these changes, the federal government also reduced fund- ing for low-income housing. As a result, many mentally ill persons who can’t afford treatment also can’t find housing. Consequently, many persons with chronic mental illness now cycle between homelessness, jail time when they prove troublesome for local authorities, and brief stays in public mental hospitals. According to the U.S. Department of Justice, more than 40% of jail inmates and 30% of prison inmates have a history of mental illness.

Despite these severe gaps in our mental health system, however, observers generally agree that deinstitutionalization improved the quality of life for most seriously mentally ill persons