Deinstitutionalization in the United States

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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.

Contents

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 three 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]

Alternatives

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]

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]

Partial hospitalization

A successful community-based alternative to institutionalization or inpatient hospitalization is partial hospitalization. Partial hospitalization programs are typically offered by hospitals, and they provide less than 24 hours per day treatment in which patients commute to the hospital or treatment center up to seven days a week and reside in their normal residences when not attending the program. [8] Patients in partial hospitalization programs show the same or greater levels of improvement as their inpatient counterparts, and unlike inpatient hospitalization, these individuals are able to maintain their familial and social roles during treatment. [9] Partial hospitalization allows for a smoother and less expensive transition between inpatient hospitalization and community life. [9] Some patients are able to avoid inpatient hospitalization altogether by participating in a partial hospitalization program, and many are able to shorten the length of their inpatient hospitalization by participating in a partial hospitalization program. [8] By eliminating or reducing the length of inpatient hospital stays, diversion to partial hospitalization programs is one important component to the process of deinstitutionalization in the United States.

Intensive outpatient programs

Intensive outpatient programs are a crucial component of the community-based care that has replaced inpatient hospitalization and institutionalization in many cases. Intensive outpatient programs provide a more cost-effective outpatient alternative to inpatient hospitalization that allows patients to receive intensive psychiatric care while still remaining in their communities, going to school, or holding a job. [10] These programs combine psychotherapy with pharmacotherapy, group therapy, substance abuse counseling, and related services in a very structured and time-intensive format, typically three hours a day, three days a week, but up to five days a week. [11] They are a less time-intensive step down from partial hospitalization, but they can provide greater support than weekly therapy appointments alone. [12] IOPs can serve as a transition between inpatient hospitalization and less intensive weekly therapy when a patient requires a greater level of care. [12] Diversion into intensive outpatient programs has reduced the number of individuals in institutionalized settings. [13]

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 Community Mental Health Act, which provided funding for community facilities that served people with mental disabilities. [1] Both acts furthered the process of deinstitutionalization. However, less than a month after signing the new legislation, JFK was assassinated and could not see the plan through. The community mental health centers never received stable funding, and even 15 years later less than half the promised centers were built.

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 favor 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, there were 340 psychiatric hospital beds for every 100,000 US citizens. 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[ clarification needed ] to promote deinstitutionalization.

The increase in homelessness was seen as related to deinstitutionalization. [14] [15] [16] 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. [17] [18]

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. [19] [20] 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, [21] being cheaper than psychiatric care. [19]

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." [22]

See also

Related Research Articles

Involuntary commitment, civil commitment, or involuntary hospitalization/hospitalisation is a legal process through which an individual who is deemed by a qualified agent to have symptoms of severe mental disorder is detained in a psychiatric hospital (inpatient) where they can be treated involuntarily. This treatment may involve the administration of psychoactive drugs, including involuntary administration. In many jurisdictions, people diagnosed with mental health disorders can also be forced to undergo treatment while in the community; this is sometimes referred to as outpatient commitment and shares legal processes with commitment.

Outpatient commitment—also called assisted outpatient treatment (AOT) or community treatment orders (CTO)—refers to a civil court procedure wherein a legal process orders an individual diagnosed with a severe mental disorder to adhere to an outpatient treatment plan designed to prevent further deterioration or recurrence that is harmful to themselves or others.

<span class="mw-page-title-main">Voluntary commitment</span> Choosing to admit oneself to a psychiatric hospital

Voluntary commitment is the act or practice of choosing to admit oneself to a psychiatric hospital, or other mental health facility. Unlike in involuntary commitment, the person is free to leave the hospital against medical advice, though there may be a requirement of a period of notice or that the leaving take place during daylight hours. In some jurisdictions, a distinction is drawn between formal and informal voluntary commitment, and this may have an effect on how much notice the individual must give before leaving the hospital. This period may be used for the hospital to use involuntary commitment procedures against the patient. People with mental illness can write psychiatric advance directives in which they can, in advance, consent to voluntary admission to a hospital and thus avoid involuntary commitment.

Partial hospitalization, also known as PHP, is a type of program used to treat mental illness and substance abuse. In partial hospitalization, the patient continues to reside at home, but commutes to a treatment center up to seven days a week. Partial hospitalization focuses on the overall treatment of the individual and is intended to avert or reduce in-patient hospitalization.

Laura's Law is a California state law that allows for court-ordered assisted outpatient treatment. To qualify for the program, the person must have a serious mental illness plus a recent history of psychiatric hospitalizations, jailings or acts, threats or attempts of serious violent behavior towards self or others. A complete functional outline of the legal procedures and safeguards within Laura's Law has been prepared by NAMI San Mateo.

Kendra's Law, effective since November 1999, is a New York State law concerning involuntary outpatient commitment also known as assisted outpatient treatment. It grants judges the authority to issue orders that require people who meet certain criteria to regularly undergo psychiatric treatment. Failure to comply could result in commitment for up to 72 hours. Kendra's Law does not mandate that patients be forced to take medication.

<span class="mw-page-title-main">Castle Peak Hospital</span> Hospital in New Territories, Hong Kong

Castle Peak Hospital is the oldest and largest psychiatric hospital in Hong Kong. Located east of Castle Peak in Tuen Mun, the hospital was established in 1961. It has 1,156 beds, providing a wide variety of psychiatric services such as adult psychiatry, forensic psychiatry, psychogeriatric services, child and adolescent psychiatry, consultation-liaison psychiatry and substance abuse treatments. All wards in the hospital are equipped to accommodate both voluntary and involuntary admitted patients.

<span class="mw-page-title-main">Community Mental Health Act</span> 1963 American law

The Community Mental Health Act of 1963 (CMHA) was an act to provide federal funding for community mental health centers and research facilities in the United States. This legislation was passed as part of John F. Kennedy's New Frontier. It led to considerable deinstitutionalization.

<span class="mw-page-title-main">Deinstitutionalisation</span> Replacement of psychiatric hospitals

Deinstitutionalisation is 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. In the late 20th century, it led to the closure of many psychiatric hospitals, as patients were increasingly cared for at home, in halfway houses and clinics, in regular hospitals, or not at all.

Assertive community treatment (ACT) is an intensive and highly integrated approach for community mental health service delivery. ACT teams serve individuals who have been diagnosed with serious and persistent forms of mental illness, predominantly but not exclusively the schizophrenia spectrum disorders. ACT service recipients may also have diagnostic profiles that include features typically found in other DSM-5 categories. Many have histories of frequent psychiatric hospitalization, substance abuse, victimization and trauma, arrests and incarceration, homelessness, and additional significant challenges. The symptoms and complications of their mental illnesses have led to serious functioning difficulties in several areas of life, often including work, social relationships, residential independence, money management, and physical health and wellness. By the time they start receiving ACT services, they are likely to have experienced failure, discrimination, and stigmatization, and their hope for the future is likely to be quite low.

<span class="mw-page-title-main">Pine Rest Christian Mental Health Services</span> Hospital in Michigan, United States

Pine Rest Christian Mental Health Services is a psychiatric hospital and behavioral health provider, with the main treatment campus located in Gaines Township, Michigan. The Chief Executive Officer and President is Dr. Mark Eastburg, appointed December, 2006.

St. Cloud Hospital is a hospital in St. Cloud, Minnesota, United States. It is a Catholic-affiliated, not-for-profit institution and part of CentraCare Health. The hospital has more than 9,000 employees, 400 physicians and 1,200 volunteers. It serves 690,000 people in a 12-county area.

<span class="mw-page-title-main">Brattleboro Retreat</span> United States historic place

The Brattleboro Retreat is a private not-for-profit mental health hospital that provides comprehensive inpatient, partial hospitalization, and outpatient treatment services for children, adolescents, and adults.

Community mental health services (CMHS), also known as community mental health teams (CMHT) in the United Kingdom, support or treat people with mental disorders in a domiciliary setting, instead of a psychiatric hospital (asylum). The array of community mental health services vary depending on the country in which the services are provided. It refers to a system of care in which the patient's community, not a specific facility such as a hospital, is the primary provider of care for people with a mental illness. The goal of community mental health services often includes much more than simply providing outpatient psychiatric treatment.

In clinical and abnormal psychology, institutionalization or institutional syndrome refers to deficits or disabilities in social and life skills, which develop after a person has spent a long period living in mental hospitals, prisons or other remote institutions. In other words, individuals in institutions may be deprived of independence and of responsibility, to the point that once they return to "outside life" they are often unable to manage many of its demands; it has also been argued that institutionalized individuals become psychologically more prone to mental health problems.

The Psychiatric Institute of Washington (PIW) is an acute psychiatric hospital in Washington, D.C. Opened in 1967, PIW is a short-term, private hospital. It offers behavioral healthcare to patients with mental and addictive illnesses, including children, adolescents, adults and the elderly. Services offered by PIW include inpatient, partial and intensive outpatient hospitalization, and group treatment programs for substance abuse and addiction.

<span class="mw-page-title-main">Torrance State Hospital</span> Hospital in Pennsylvania, United States

Torrance State Hospital is one of six State Hospitals in the Commonwealth of Pennsylvania.

<span class="mw-page-title-main">New York State Department of Mental Hygiene</span>

The Department of Mental Hygiene (DMH) is a component of the New York state government composed of three autonomous offices:

<span class="mw-page-title-main">Homelessness and mental health</span>

In a study in Western societies, homeless people have a higher prevalence of mental illness when compared to the general population. They also are more likely to suffer from alcoholism and drug dependency. It is estimated that 20–25% of homeless people, compared with 6% of the non-homeless, have severe mental illness. Others estimate that up to one-third of the homeless have a mental illness. In January 2015, the most extensive survey ever undertaken found 564,708 people were homeless on a given night in the United States. Depending on the age group in question and how homelessness is defined, the consensus estimate as of 2014 was that, at minimum, 25% of the American homeless—140,000 individuals—were seriously mentally ill at any given point in time. 45% percent of the homeless—250,000 individuals—had any mental illness. More would be labeled homeless if these were annual counts rather than point-in-time counts. Being chronically homeless also means that people with mental illnesses are more likely to experience catastrophic health crises requiring medical intervention or resulting in institutionalization within the criminal justice system. Majority of the homeless population do not have a mental illness. Although there is no correlation between homelessness and mental health, those who are dealing with homelessness are struggling with psychological and emotional distress. The Substance Abuse and Mental Health Services Administration conducted a study and found that in 2010, 26.2 percent of sheltered homeless people had a severe mental illness.

Involuntary commitment or civil commitment is a legal process through which an individual who is deemed by a qualified agent to have symptoms of severe mental disorder is detained in a psychiatric hospital (inpatient) where they can be treated involuntarily.

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. Archived from the original on 2013-12-20.
  3. ↑ "Sproutflix website description of film titled Willowbrook: The Last Great Disgrace". Archived from the original on 24 July 2012. Retrieved 6 October 2014.
  4. ↑ Duggar, Celia W. (March 12, 1993). "Big Day for Ex-Residents Of Center for the Retarded". The New York Times .[ permanent dead link ]
  5. ↑ NYS Office For People With Developmental Disabilities, article title Milestones in OMRDD's History Archived 2011-08-09 at the Wayback Machine
  6. ↑ Museum of DisABILITY History, article title The New York State Timeline Archived 2012-04-20 at the Wayback Machine
  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. 1 2 "Definition of partial hospitalization. The National Association of Private Psychiatric Hospitals and the American Association for Partial Hospitalization". The Psychiatric Hospital. 21 (2): 89–90. 1990. ISSN   0885-7717. PMID   10106610.
  9. 1 2 Pang, J. (September 1985). "Partial hospitalization. An alternative to inpatient care". The Psychiatric Clinics of North America. 8 (3): 587–595. doi:10.1016/S0193-953X(18)30682-8. ISSN   0193-953X. PMID   4059096.
  10. ↑ Smith, George W.; Ruiz-Sancho, Ana; Gunderson, John G. (2001-04-01). "An Intensive Outpatient Program for Patients With Borderline Personality Disorder". Psychiatric Services. 52 (4): 532–533. doi:10.1176/appi.ps.52.4.532. ISSN   1075-2730. PMID   11274503.
  11. ↑ Treatment, Center for Substance Abuse (2006). Chapter 4. Services in Intensive Outpatient Treatment Programs. Substance Abuse and Mental Health Services Administration (US).
  12. 1 2 Seton, Ascension (2017-02-06). "What to Expect from an Intensive Outpatient Program". Behavioral Health Care. Retrieved 2020-08-25.
  13. ↑ ATWELL, ROBERT H. (1965). "Recent Trends and Current Problems In Mental Health Services". Inquiry. 2 (4): 3–12. ISSN   0046-9580. JSTOR   41348527.
  14. ↑ Scanlon, John (2 October 1989). "Homelessness: Describing the Symptoms, Prescribing a Cure". Backgrounder. Heritage Foundation. 729. Archived from the original on 2 October 2008. Retrieved 30 June 2016.
  15. ↑ 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.
  16. ↑ Friedman, Michael B. (8 August 2003). "Keeping The Promise of Community Mental Health". The Journal News. Archived from the original on September 27, 2007.
  17. ↑ 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. Archived from the original on 2013-04-15.
  18. ↑ 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.
  19. 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.
  20. ↑ 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   1361075 . PMID   15333114.
  21. ↑ Roche, Timothy (10 July 2000). "The Chief and His Ward". Time . Archived from the original on November 22, 2010. Retrieved 12 November 2010.
  22. ↑ Mac Donald, Heather. "The Jail Inferno". City Journal. Archived from the original on 28 May 2010. Retrieved 27 July 2009.
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