MH@H Mental Health

The Downside of Psychiatric Deinstitutionalization

The downside of deinstitutionalization - image of an asylum

Now is a far better time to be mentally ill than it was a few hundred years ago. Institutions like the infamous Bedlam were not happy places, and you might just find yourself chained to the wall for years on end.

prisoner shackled to his bed in Bedlam Asylum
James Norris at Bedlam, circa 1814

In the 1800s, you may have ended up in the Trans-Allegheny Lunatic Asylum in Weston, West Virginia for “imaginary female troubles” or “fits and desertion of husband.”

In the early 1900s, Dr. Henry Cotton, head of the New Jersey State Hospital at Trenton, started doing surgeries to remove rather crucial body parts (like the colon) from the crazy folk, most of whom died afterwards.

Deinstitutionalization in the US

Moving mentally ill people out of the institutions where they’d been locked up seemed like a good idea. In 1963, the United States enacted the Community Mental Health Act, John F. Kennedy’s 3-year plan to move people out of “custodial isolation” in asylums and back to the community.  Community mental health centres were supposed to take over care

Of course, the funding didn’t come close to matching the need.  The most severely ill fell through the very wide cracks, producing homelessness and a shift to the correctional system in mass numbers.  President Ronald Reagan later furthered deinstitutionalization and slashed funding to support the mentally ill, which of course only worsened the problem. 

Reagan-era legislation also shifted decision-making around involuntary committal from medical professionals to the courts. While that could have been a good thing, in practice, it made it more difficult to commit people. That’s great if it’s keeping people out of hospital that don’t need to be there; however, it’s not so good when it’s highly vulnerable people who don’t have other options.

Consequences

Then you get situations like the documentary God Knows Where I Am. It tells the heartbreaking story of a woman whose bipolar psychosis couldn’t be treated in hospital because that would have required a guardianship order, which a court would not approve. Since the hospital’s hands were tied, they discharged her. She lived for three months squatting in an empty house before starving to death in the wintertime.

While deinstitutionalization is absolutely good for people who don’t need it, there are a lot of people who can end up falling through the cracks without adequate community supports. In the city where I live, closure of the major provincial psychiatric hospital, a process that happened over a few decades, contributed significantly to my city’s large skid row population. Here as in elsewhere, deinstitutionalization has led to significant increases in homelessness.

Some people have very high care needs due to their mental illness. Promoting independence is generally a good thing, but for people who don’t have the capacity, independence simply means their needs don’t get met, like the need for safe shelter, healthy food, personal hygiene, etc. That’s not necessarily a better life than living in a setting that meets their care needs.

I’m by no means arguing for people to get locked up in institutions on masse. However, not providing adequate support could mean getting locked up somewhere else; in the U.S. in 2003, there are more than three times as many people with mental illness in the prison system as in psychiatric hospitals (figure from Cornell University). The massive jump in numbers of mentally ill in correctional facilities happened at the very same time that psychiatric institutions were closing.

Is there a better way?

Better funding for community mental health would make a big difference. Somewhere, I think there’s a balance to be found between offering people the level of support they need to function without being more restrictive than necessary. Choice is important, and autonomous decision-making doesn’t always mean independent living. People are able to thrive when the level of support they get matches what they need. When you dump people into independent community living and they don’t have the skills, and perhaps don’t have the capacity, it isn’t going to help them thrive. It’s more likely to help them be that scary crazy person who seems to fit all of those scary crazy people stereotypes that people hold. It’s probably not what anyone had in mind with deinstitutionalization.

Where do you think the balance might lie between giving people the support they need without overstepping?

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23 thoughts on “The Downside of Psychiatric Deinstitutionalization”

  1. It’s interesting to watch Girl, Interrupted and to know that they kept her in the institution for ages even though nowadays, she’d have been out in a week or two and given resources. And one reason I love I Never Promised You a Rose Garden is the sense I get that the staff were trying as hard as they could in the pre-medication days to help the patients. But yeah, there has to be a functional balance that benefts people and prevents anyone from falling through the cracks.

    Is this a preview of your upcoming book? It’s very informative and loaded with content!! Great post! “Imaginary female troubles,”? Oh my goodness. Commit me!

    1. Haha that was from a post I did quite a while back with a list of reasons for admission to an asylum back when. It was pretty funny.

  2. I disagree with the assertion that “closure of the major provincial psychiatric hospital, a process that happened over a few decades, contributed significantly to my city’s large skid row population”. I firmly believe it is the lack of community services that contributes to this problem.

  3. Deinstitutionalization has been a problem since the 1970s, when I worked on an abortive dissertation on the process in New Jersey. In my view, much of the impetus wasn’t about improving the lives of the ill, but rather about reducing the funding burden on state and local government, pushing it back onto stressed-out families.

    Truth seems to be that despite a few pilot projects to provide jobs for the ill, we still don’t know what to do with them. Families that can provide trusts for the ill at least cover them financially, to a point. However, most families can’t do that. The social “safety net” only goes so far. And then, how do you keep them occupied during the day?

    Finally, we have the psychiatry handbook, which, out of self-interest, has developed a typology that makes virtually everyone classifiable in some way, taking focus away from those most in need.

    As usual, humans have made a puzzle more complicated and harder to solve in the name of progress.

    1. It seems like it really shouldn’t be that hard to have dignified, supportive communities that help people like active, meaningful lives, but like you said, we tend to make things more difficult than they need to be.

      1. One classic definition of politics is “deciding whose ox is getting gored.” That is, who takes the burden for paying for a project. That issue factors into and distorts every public initiative, and least in countries where greed dominates thought.

        1. And of course politics is all about costs right now; savings down the road might be something someone else gets to take credit for.

  4. Ashley this is such an important topic. The cracks in the system (here) are incredibly large. You capture the related issues so well in your article. I always think the foundational answer is in real investment in families and children. I also always think supporting independence is important, and when supports are needed a better system which could better support solid informed assessment of need and case management -that is genuinely informed by the need-aiding in day to day needs, medical and behavioral health needs, recreational, social. I feel so many people live utterly alone with no resources or supportive alliances. As I write, a response to your thought provoking question I think there are many things true reform and funding spent here could alleviate.

    1. I wonder if an assisted living model might be helpful for people who don’t have the skills for fully independent living, with peer-run social and recreational programming. Given the high cost of hospitalizing people, providing a high level of support for those who need it in the community should still yield a cost savings overall. I can also see that kind of model working well to provide respite for families who are supporting a loved one with mental illness.

  5. In the UK there are supported living houses, where people can make the transition from bring in hospital to back in the community. I think beds are really hard to come by though. It’s sad that so many governments don’t adequately fund MH services, you’d think it would save them money in the long run.

  6. Having watched programmes similar to the one you mentioned, I too agree that de-institutionalising was bad for some patients. I saw many patients in an out of our rehab wards because they couldn’t make it on their own.

    How many times do these ‘revolving door’ patients have to be picked up off the streets by the police, put back into acute care then rehab before they’re discharged too early yet again. It’s de-humanising for this group of patients and I don’t think our UK Community Mental Health Teams have the funding, the passion or wherewithal to look after them.

  7. I do think vulnerable peoples needs should be considered, some people cant live alone, their mental health is too bad, or they have no skills to look after themselves, I’ve known plenty of people who were in that position. I’ve also known some people who try to get hospitalised at every turn, its like they choose the hospital and its like a safe place for them and once they are in there they don’t want to leave! I knew one girl who was in there for 11 months! She was so scared to go home after being in there for so long!

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