Good Intentions, Deinstitionalization, and the Road to Hell: How Advocates for the Mentally-ill Harmed
There is no question that by the middle of the twentieth century the public mental health system was in desperate need of reform. For the seriously mentally-ill, particularly those without access to considerable financial resources, the only recourse was admission into a state mental hospital. Unfortunately, these institutions were becoming increasingly ill-equipped to effectively treat an ever-increasing patient population. By the time John F. Kennedy’s administration passed the Community Mental Health Act, which laid the groundwork for deinstitutionalization, the deficiencies of the state mental hospitals were so severe that admission for many likely did more harm than good (Gilligan, 2001). Partly as a result of the dismal quality of treatment at state institutions, and partly as a result of several other developments within American society as a whole and the mental health field specifically, the latter half of the twentieth century witnessed a massive exodus of mental patients from the state hospitals into the general population (Morrissey & Goldman, 1984). While many advocates for the mentally-ill, particularly those who had pushed for this depopulation, lauded the emptying and closing of wards across the country, few if any questioned whether this change could actually lead to worse conditions for former patients or for those who might in the future need such care.
In the decades following the beginning of deinstitutionalization, it has become increasingly clear that however inadequate or even harmful state mental hospitals may have been, the decision to close them was a poor one. It resulted in greater, not fewer, problems for several disadvantaged groups, and individuals within any one group often additionally belonged to several (as the mentally-ill are often economically disadvantaged, minorities, etc). There was simply no adequate alternative to the state hospitals which were in place when they began to be emptied, nor has any been developed since. For many former mental patients—particularly the severely mentally-ill, racial minorities, and the economically disadvantaged—reintegration into the community was virtually impossible. Without sufficient communal support in place, the prison system gradually became the new state ward, and those who managed to escape incarceration faced homelessness in its stead. Deinstitionalization was simply another example in the history of mental health treatment of a “revolution” which caused more harm than good.
In order to understand not only the issues associated with deinstitutionalization, but also the factors involved in the push for the process itself, some diachronic analysis is necessary. As with deinstitutionalization, the birth and subsequent growth of asylums as well as state responsibility for the mentally-ill were attempts to improve the situation for those suffering from mental disorders (Rothman, 2002). First, a great many mentally-ill individuals prior to the alternative of asylums found themselves in prisons (Rothman, 2002; Gilligan, 2001). Second, the proponents of institutionalization (most of whom were psychiatrists) believed that the causes of mental disorders were primarily environmental and social. By removing individuals from their normal environments and providing them with stable, consistent replacement environments, it was believed that asylums could rehabilitate the mentally-ill (Rothman, 2002). Indeed, for many years asylums offered a vast improvement over formerly available recourses for the mentally-ill (Rothman, 2002). For the most part, hospital administrators and staff alike, far from being real-life examples of the cruel and vindictive Nurse Ratched from “One Flew Over the Cuckoo’s Nest,” were humanitarians and their treatment consisted of entertainment and a warm, caring, atmosphere (Morrissey & Goldman, 1984).
Unfortunately, the various treatment methods employed in state hospitals were met with limited success. Not only was rehabilitation the exception, rather than the rule, as the optimism which had motivated the push for institutionalism faded along with a lack of effective treatment, so too did the number of patients grow (Morrissey & Goldman, 1984). Increasingly, state mental institutions assumed responsibility for all manner of individuals exhibiting abnormal behavior (from the psychotic to the senile) and became less and less places devoted to treatment and more and more holding cells which served primarily to provide a location to which such individuals could be sent to remove them from society (Morrissey & Goldman, 1984). By the 1950s, the average patient population of public mental hospitals was in excess of half a million (Horowitz, 2002). Hospital staffing, by contrast, was far too insufficient to do much more than provide patients with basic necessities and a place of residence. Nonetheless, it is important to note that despite the increasing deficiencies (many related to patient overpopulation) of state institutions, they nonetheless provided some measure of consistent care which would likely not have been available elsewhere (Morrissey & Goldman, 1984).
However, beginning in the 1950s, and partly in response to the dismal conditions of state hospitals, a push towards community care grew within the mental health community (Morrissey & Goldman, 1984). The conditions within state mental hospitals ceased to be viewed as tolerable or necessary, but rather cruel and inhumane (Gilligan, 2001). Under John F. Kennedy, congress passed the Community Mental Health Act, legislation which was based on (among other things) research indicating that communal programs such as halfway houses would provide superior treatment for those with mental disorders (Morrissey & Goldman, 1984; Sue, Sue, & Sue, 2010). Once again, this reform was motivated primarily by a desire to help the mentally-ill and improve their conditions. The results, however, were far less beneficial than advocates had hoped.
The primary reason for the failure of deinstitutionalization was a lack of available community support programs. The process of emptying out the state hospital populations began before ensuring that community resources would be in place when patients were to be released. Furthermore, these resources never materialized in adequate numbers which would enable them to serve the vast majority of former patients, primarily because government funds were never allocated in sufficient amounts (Comer, 2007). Another fundamental problem was a failure to implement the necessary programs even when funds were available. Although the government and mental health professionals believed that community care was the best method for caring for the mentally-ill, the public was willing to go along with such plans only insofar as their particular communities were not among those in which programs for such care were built (Gilligan, 2001). As a result, even today a majority of those suffering from serious mental illness receive less than minimal care (Wang, Demler, & Kessler, 2002).
Without the necessary community support programs in place, as state institutions continued to depopulate and subsequently close, no adequate resources to treat or care for the seriously mentally-ill (excepting those with financial resources, who were in the vast minority) materialized. As a result, the vast majority of those who would have found themselves in long-term state care wound up in one of two places: on the streets (homeless) or in prison (Markowitz, 2006). This is particularly ironic, as it was activists and mental health advocates in the 19th century (e.g. Dorothea Dix) who pushed for asylums to provide alternatives to exactly these conditions: incarceration and homelessness.
Estimates of the US homeless population, as well as rates of mental illness among them, are of course difficult to assess with great accuracy. Nevertheless, of the probable quarter to over half a million homeless living in America, perhaps one third possess one or more severe mental disorders (Comer, 2007). Although clearly not all of homelessness, even among the mentally-ill, resulted from deinstitutionalization, it is clear that this process was responsible for greatly increasing the number of homeless across the country as no suitable alternative to the state hospitals (where such individuals could have previously found residence) was ever provided (Sue, Sue, & Sue, 2010; Markowitz, 2006). Even among those individuals who managed to find accommodations, over one-third live unsupervised (Comer, 2007) and the majority do not receive minimal care for their disorders (Wang, Demler, & Kessler, 2002). Unfortunately, as horrific as mass homelessness and lack of care for the mentally-ill is, these factors are also precursors of a far more serious development within the mental health system.
Without medication, therapy, a place to live, or communal support, a frequent result for the severely mentally-ill is arrest and subsequent imprisonment (Gilligan, 2002). In fact, the decreasing mental hospital population has resulted in an unprecedented rise in the nation’s prison population (Gilligan, 2002). So frequently are arrest and incarceration used as methods to regulate the behavior of the mentally-ill that, for example, more schizophrenics reside in prison than are homeless (Comer, 2007). The state hospitals, whatever their shortcomings may have been, have simply been replaced by another type of state institution and one which can hardly be said to be an improvement.
The prison system is not the only new component of today’s mental health field. As more and more of the seriously mentally-ill are without adequate residence and/or care, their primary “social workers” have become police. The tendency for delusional, paranoid, and/or otherwise severely disturbed individuals (who, with medication and proper management could very likely improve significantly) to create public disturbances is all too common (Teplin & Pruett, 1992). The result is that the first people called to manage these individuals are police. Too often, though, there is little the police can do. The majority of the severely disturbed do not have adequate insurance to be admitted into private hospitals—which are short term anyway (Teplin & Pruett, 1992). The police can either attempt to quell the situation on scene (if possible) or arrest the individual involved. Therefore, the arrest rate for the mentally-ill is significantly greater than for those without mental illness, simply because more often than not this is the only available recourse the police possess to deal with the severely disturbed (Teplin & Pruett, 1992).
Arrest is not the end of the interaction between the mentally-ill and the justice system. With greater and greater frequency, courts simply send the mentally-ill who are arrested to prison. Over one sixth of all inmates, whether confined to federal or state prisoners or local jails, have been diagnosed with mental illnesses (Markowitz, 2006). There are more mentally-ill individuals in the jails and prisons than in mental hospitals (Markowitz, 2006). As a result, prisons across the country have been forced to adapt to deal with this new type of inmate.
This relegation of the mentally-ill to prisons fails even when it succeeds. In prisons which have not at least minimally adapted (or adopted) procedures to deal with mentally-ill inmates, such inmates are often severely abused (Torrey, 1995). This abuse comes not only from other prisoners, who frequently are unwilling to tolerate the behavior of their mentally-ill fellow inmates, but also from guards (Torrey, 1995). In one well-publicized incident, guards beat a mentally-ill inmate so severely he suffered permanent brain damage (Torrey, 1995).
On the other hand, the better prison systems which do attempt to alter policies and adapt to aid the portion of the prison population with mental illness are victims of their own success. They have become the “bottom-line” mental health providers (Torrey, 1995). Many correctional facilities do provide at least minimal mental health services (Markowitz, 2006). However, this success comes at too severe a cost. The better prisons are at managing and caring for the mentally-ill, a task the prison system was never intended for, the more social & political systems rely on prisons to care for the mentally-ill (The New Asylums, 2005).
The situation for the severely mentally-ill has, in many ways, returned to what it was over a century and a half ago. Once more, prisons and jails have become the primary housing and “treatment” centers for the mentally-ill. This development is a direct result of the well-intentioned movement to depopulate the state mental hospitals and integrate the mentally-ill into the community. The movement, alas, was an abject failure. Communities were simply not ready to accept the new population, nor have any significant strides been made since the beginning of deinstitutionalization. This does not mean, of course, that no attempts at improving the lot of the mentally-ill should have been made at all. Certainly, to the extent they are feasible, community outreach programs should be instituted whenever possible. However, without institutions large enough to support large numbers of the mentally-ill for extended periods of time, the alternative for these individuals will either be homelessness or incarceration. It is necessary to consider reinstituting state mental hospitals as a viable option. Even at their worst, such places were superior to most prisons, and it would be easier and more economical to reform mental hospitals rather than to continue to burden both the judicial system and the prison system with those who should be treated rather than punished. It is time to consider reinstitutionalization, albeit with improvements, as a means of treating, supporting, and caring for the mentally-ill.
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