Deinstutionalization: The Illusion of Policy
Published online by Cambridge University Press: 14 October 2011
In mid-nineteenth century America the asylum became the foundation of public policy. This ubiquitous institution was regarded as a symbol of an enlightened and progressive nation that no longer ignored or mistreated its severely and chronically mentally ill citizens. The faith in an institutional policy was embodied in a vast and costly system of state mental hospitals that by 1940 had an inpatient population of about 450,000. Despite the presence of serious problems, there was little disposition to call into doubt the wisdom of institutional care and treatment. Even though mental health policy was formulated within a decentralized and divided political system, there was no doubt that a holistic and clear consensus prevailed.
- Journal of Policy History , Volume 9 , Special Issue 1: Health Care Policy in Contemporary America , January 1997 , pp. 48 - 73
- Copyright © The Pennsylvania State University, University Park, PA. 1997
1. See for example the data provided by Jarvis, Edward in his Report on Insanity and Idiocy in Massachusetts by the Commission on Lunacy Under Resolve of the Legislature of 1854 (Mass. House Document No. 144 ) (Boston 1855), 18, 73.Google Scholar
2. For discussions of this theme, see Grob, Gerald N., Mental Illness and American Society, 1875–1940 (Princeton, 1983)Google Scholar, From Asylum to Community: Mental Health Policy in Modern America (Princeton, 1991)Google Scholar, and “Government and Mental Health Policy: A Structural Analysis,” Milbank Quarterly 72 (1994): 471–500.CrossRefGoogle Scholar
3. Dwyer, Ellen, Homes for the Mad: Life Inside Two Nineteenth-Century Asylums (New Brunswick, 1987), 150–51Google Scholar; U.S. Bureau of the Census, Insane and Feeble-Minded in Hospitals and Institutions 1904 (Washington, D.C., 1906), 37Google Scholar; idem., Insane and Feeble Minded in Institutions 1910 (Washington, D.C., 1915), 59; idem., Patients in Hospitals for Mental Disease, 1923 (Washington, D.C., 1926), 36; Dayton, Neil A., New Facts on Mental Disorders: Study of 89,190 Cases (Springfield, Ill., 1940), 414–29.Google Scholar
4. Malzberg, Benjamin, “A Statistical Analysis of the Ages of First Admissions to Hospitals for Mental Disease in New York State,” Psychiatric Quarterly 20 (1949): 344–66CrossRefGoogle Scholar; idem., “A Comparison of First Admissions to the New York Civil State Hospitals During 1919–1921 and 1949–1951,” ibid. 28 (1954): 312–19; New York State Department of Mental Hygiene, Annual Report, 42 (1939–1940): 174–75Google Scholar; Goldhamer, Herbert and Marshall, Andrew W., Psychosis and Civilization: Two Studies in the Frequency of Mental Disease (Glencoe, Ill., 1953), 54, 91Google Scholar; American Psychiatric Association, Report on Patients Over 65 in Public Mental Hospitals (Washington, D.C., 1960), 5.Google Scholar
5. Statistics compiled from U.S. Bureau of the Census, Patients in Hospitals for Mental Disease 1923, and Mental Patients in State Hospitals 1926 and 1927 (Washington, D.C., 1930)Google Scholar, Patients in Mental Hospitals 1940 (Washington, D.C., 1943)Google Scholar, and Kramer, Morton, Psychiatric Services and the Changing Institutional Scene, 1950–1985 (DHEW Publication No. [ADM] 76–374: Washington, D.C.: Government Printing Office, 1977), 75.Google Scholar
6. Grob, From Asylum to Community, passim.
7. The most famous included Albert Q. Maisel, “Bedlam 1946,” Life 20 (May 6, 1946): 103–18; Wright, Frank L., Out of Sight Out of Mind (Philadelphia, 1947)Google Scholar; Gorman, Mike, “Oklahoma Attacks Its Snakepits,” Reader's Digest 53 (September 1948): 139–60Google Scholar; and Deutsch, Albert, The Shame of the States (New York, 1948)Google Scholar. Ward's, Mary Jane novel The Snake Pit (New York, 1946)Google Scholar, was subsequently made into a famous motionpicture in 1948.
8. For a detailed discussion of the expanded role of the federal government, see Grob, From Asylum to Community.
9. Sampson, Harold, Ross, David, Engle, Bernice, and Livson, Florine, “Feasibility of Community Clinic Treatment for State Mental Hospital Patients,” Archives of Neurology and Psychiatry 80 (1958): 77CrossRefGoogle ScholarPubMed. A larger version of this study appeared under the tide A Study of Suitability for Outpatient Clinic Treatment of State Mental Hospital Admissions 1957, California Department of Mental Hygiene Research Report No. 1 (1957).
10. See Kramer, Morton, Some Implications of Trends in the Usage of Psychiatric Facilities for Community Mental Health Programs and Related Research (U.S. Public Health Service Publication 1434: Washington, D.C., 1967)Google Scholar; idem., “Epidemiology, Biostatistics, and Mental Health Planning,” in American Psychiatric Association Psychiatric Research Reports 22 (1967): 1–68; TaubeKramer, C. Kramer, C., and Starr, S., “Patterns of Use of Psychiatric Facilities by the Aged: Current Status, Trends, and Implications,” in American Psychiatric Association Psychiatric Research Reports 23 (1968): 89–150.Google Scholar
11. Langsley, Donald G., “The Community Mental Health Center: Does It Treat Patients?,” Hospital & Community Psychiatry 31 (1980): 815–19Google ScholarPubMed; Bass, Rosalyn D., CMHC Staffing: Who Minds the Store? (DHEW Publ. [ADM] 78–686: Washington, D.C., 1978)Google Scholar; Dowell, David A. and Ciarlo, James A., “An Evaluative Overview of the Community Mental Health Centers Program,” in Handbook on Mental Health Policy in the United States, ed. Rochefort, David A. (Westport, Conn., 1989), 206.Google Scholar
12. This paragraph is based upon an examination of the following sources: 92–2 Congress, Extend Community Mental Health Centers Act: Hearing before the Subcommittee on Public Health and Environment of the Committee on Interstate and Foreign Commerce House Representatives… 1972 (Washington, D.C., 1972); 93–1Google Scholar Congress, Public Health Service Act Extension 1973: Hearing before the Committee on Labor and Welfare United States Senate …1973 (Washington, D.C., 1973); 93–1Google Scholar Congress, Departments of Labor, and Health, Education and Welfare and Related Agencies Appropriations for Fiscal Year 1974: Hearings before a Subcommittee of the Committee on Appropriations United States Senate (Washington, D.C., 1973)Google Scholar; General Accounting Office, “Community Mental Health Centers Program-Improvements Needed in Management,” July 8, 1971 (B-164031) and “Need for More Effective Management of Community Mental Health Centers Program,” August 27,1974 (B-164031); Public Law 94–63, U.S. Statutes at Large, 89:304–369 (July 29, 1975), Public Law 95–83, ibid., 91:383–399 (August 1, 1977), and Public Law 95–622, ibid., 92:3412–3442 (November 9, 1978). For analyses of the policy debates of the early 1970s see Foley, Henry A., Community Mental Health Legislation: The Formative Process (Lexington, 1975)Google Scholar; Barton, Walter E. and Sanborn, Charlotte J., eds., An Assessment of the Community Mental Health Movement (Lexington, 1977)Google Scholar; Foley, Henry A. and Sharfstein, Steven S., Madness and Government: Who Cares for the Mentally Ill? (Washington, D.C., 1983)Google Scholar; Torrey, E. Fuller, Nowhere to Go: The Tragic Odyssey of the Homeless Mentally Ill (New York, 1988)Google Scholar; and Lisa Reichenbach, “The Federal Community Mental Health Centers Program and the Policy of Deinstitutionalization,” mss. prepared for the NIMH under Grant No. MH27738–02 (1980).
13. Report to the President from The President's Commission on Mental Health 1978 (4 vols.: Washington, D.C., 1978)Google Scholar; General Accounting Office, Returning the Mentally Disabled to the Community: Government Needs to Do More (Washington, D.C., 1977)Google Scholar; Mental Health Systems: Message from the President of the United States (May 15, 1979) (Washington, D.C., 1979); 96–1Google Scholar Congress, Mental Health Systems Act, 1979: Hearings before the Subcommittee on Health and Scientific Research of the Committee on Labor and Human Resources United States Senate … 1979 (Washington, D.C., 1980); 96–1Google Scholar Congress, Mental Health Systems Act: Hearings before the Subcommittee on Health and the Environment of the Committee on Interstate and Foreign Commerce House of Representatives … 1979 (Washington, D.C., 1979); 96–2Google Scholar Congress, Community Mental Health Centers, Oversight: Hearing before the Subcommittee on Health and the Environment of the Committee on Interstate and Foreign Commerce House of Representatives … 1980 (Washington, D.C., 1980)Google Scholar; Public Law 96–398, U.S. Statutes at Large, 94: 1564–1613 (October 7, 1980). The best description of the history of the act is Foley and Sharfstein, Madness and Government, 118–34.
14. The literature dealing with mental health law since the 1960s is immense. For overviews see the following: Brooks, Alexander D., Law, Psychiatry and the Mental Health System (Boston, 1974)Google Scholar, and the 1980 Supplement (Boston, 1980) to this volume; Mechanic, David, Mental Health and Social Policy (3rd ed.: Englewood Cliffs, New Jersey, 1989), 213–34Google Scholar; Appelbaum, Paul S., “The Right to Refuse Treatment with Antipsychotic Medications: Retrospect and Prospect,” American Journal of Psychiatry 145 (1988): 413–19Google ScholarPubMed; Gerald L. Klerman, “The Psychiatric Patient's Right to Effective Treatment: Implications of Osheroff v. Chestnut Lodge,” ibid., 147 (1990): 409–18; Alan A. Stone, “Law, Science, and Psychiatric Malpractice: A Response to Klerman's Indictment of Psychoanalytic Psychiatry,” ibid., 419–27.
15. See Stone, Alan, “Overview: The Right to Treatment—Comments on the Law and Its Impact,” American Journal of Psychiatry 132 (1975): 1125–34.Google Scholar
16. Group for the Advancement of Psychiatry, Report No. 79 (November 1970): 662; Vladeck, Bruce C., Unloving Care: The Nursing Home Tragedy (New York, 1980).Google Scholar
17. General Accounting Office, Returning the Mentally Disabled to the Community, 81; Johnson, Ann B., Out of Bedlam: The Truth About Deinstitutionalization (New York, 1990), 94–5Google Scholar; Rice, Dorothy P., Kelman, S., Miller, L. S., and Dunmeyer, S., The Economic Costs of Alcohol and Drug Abuse and Mental Illness: 1985 (San Francisco, 1990), 76, 108, 110.Google Scholar
18. Public Law 92–603, U.S. Statutes at Large, 86:1329–1492 (October 30, 1972); Johnson, Out of Bedlam, 96–9. See also Berkowitz, Edward D., Disabled Policy: America's Programs for the Handicapped (New York, 1987).Google Scholar
19. The claim that the massive decline in the number of inpatients at state mental hospitals began with the development of the psychotropic drugs in the 1950s in simply not substantiated by the data. See especially Gronfein, William, “Incentives and Intentions in Mental Health Policy: A Comparison of the Medicaid and Community Mental Health Programs,” Journal of Health and Social Behavior 26 (1985): 192–206.CrossRefGoogle ScholarPubMed
20. NIMH, Mental Health United States, 1990, ed. Manderscheid, Ronald W. and Sonnenschein, Mary A. (Washington, D.C., 1990), 31Google Scholar, 158, 160; Mechanic, David and Rochefort, D. A., “Deinstitutionalization: An Appraisal of Reform,” Annual Review of Sociology 16 (1990); 308–13CrossRefGoogle Scholar; Joseph P. Morrissey, “The Changing Role of the Public Mental Hospital,” in Handbook on Mental Health Policy, ed. D.A. Rochefort, 311–38; Goldman, Howard, Taube, C. A., Regier, D. A., and Witkin, M., “The Multiple Functions of the State Mental Hospital,” American Journal of Psychiatry 140 (1983): 296–300.Google ScholarPubMed
21. See especially Henry Santiestevan, Deinstitutionalization: Out of Their Beds and into the Streets, a pamphlet published by the American Federation of State, County and Municipal Employees in 1975 and reprinted in the American journal of Psychiatry 132 (1975): 95–137.
22. Goldman, Howard H., Adams, N. H., and Taube, C. A., “Deinstitutionalization: The Data Demythologized,” Hospital & Community Psychiatry 34 (1983): 129–34Google ScholarPubMed; Guderman, Jon E. and Shore, Miles F., “Beyond Deinstitutionalization: A New Class of Facilities for the Mentally III,” New England Journal of Medicine 311 (1984): 832–35.CrossRefGoogle Scholar
The persistence of the state hospital, as a matter of fact, is mirrored in a variety of data. Between 1969 and 1983 expenditures for state hospital systems increased in current dollars from $1.8 to $5.5 billion (in constant dollars there was a slight decline from $1.8 to $1.7 billion). In 1986 there were 286 state and county hospitals, eleven more than in 1955 but down from the high of 334 in 1973. See NIMH, Mental Health, United States, 1987. ed. Manderscheid, Ronald W. and Barrett, S. A. (Washington, D.C., 1987), 56–57Google Scholar, and Mechanic and Rochefort, “Deinstitutionalization,” 308ff.
23. Courtenay M. Harding, George W. Brooks, Takamaru Ashikaga, John S. Strauss, and Alan Breier, “The Vermont Longitudinal Study of Persons with Severe Mental Illness, I: Methodology, Study Sample, and Overall Status 32 Years Later,” and “The Vermont Longitudinal Study of Persons with Severe Mental Illness, II: Long Term Outcome of subjects Who Retrospectively Met DSM-III Criteria for Schizophrenia,” American Journal of Psychiatry 144 (1986): 718–35.Google Scholar
24. Leete, Esso, “The Treatment of Schizophrenia: A Patient's Perspective,” Hospital & Community Psychiatry 38 (1987): 486–91Google ScholarPubMed; Rosenfield, Sarah, “Factors Contributing to the Subjective Quality of Life of the Chronic Mentally III,” Journal of Health and Social Behavior 33 (1992): 299–315.CrossRefGoogle Scholar
In an as yet unpublished study, Allan Horwitz interviewed 142 individuals on the threshold of release from a mental hospital. Not a single individual expressed a preference for institutionalization; all looked forward to resuming their lives in the community. Allan Horwitz, personal communication, June, 1993.
25. U. S. Bureau of the Census, Historical Statistics of the United States, Colonial Times to 1970 (2 vols.: Washington, D.C. 1975), 1, 49Google Scholar; Kramer, Psychiatric Services and the Changing Institutional Scene, 1950–1985, 46; Bachrach, Leona L., “Young Adult Chronic Patients: An Analytical Review of the Literature,” Hospital & Community Psychiatry 33 (1982): 189–97.Google ScholarPubMed
26. Pepper, Bert, Ryglewicz, H., and Kirschner, M. C., “The Uninstitutionalized Generation: A New Breed of Psychiatric Patient,” in The Young Adult Chronic Patient, ed. Pepper, and Ryglewicz, (San Francisco, 1982), 5Google Scholar. See also Bachrach, , “The Homeless Mentally III and Mental Health Services: An Analytical Review of the Literature,” in The Homeless Mentally III: A Task Force Report of the American Psychiatric Association, ed. Lamb, H. Richard (Washington, D.C., 1984), 11–53.Google Scholar
27. Bachrach, , “The Concept of Young Adult Chronic Psychiatric Patients: Questions from a Research Perspective,” Hospital & Community Psychiatry 35 (1984): 574Google ScholarPubMed; Lamb, “Deinstitutionalization and the Homeless Mentally III,” in The Homeless Mentally Ill, 65.
28. Fischer, Pamela J. and Breakey, W. R., “The Epidemiology of Alcohol, Drug, and Mental Disorders Among Homeless Persons,” American Psychologist 46 (1991): 1115–28CrossRefGoogle ScholarPubMed; Deborah L. Dennis, J. C. Buckner, F. R. Lipton, and I. S. Levine, “A Decade of Research and Services for Homeless Mentally Ill Persons,” ibid., 1129–38; Dennis McCarty, M. Algeriou, R. B. Huebner, and B. Lubran, “Alcoholism, Drug Abuse, and the Homeless,” ibid., 1139–48; Robert E. Drake, F. C. Osher, and M. A. Wallach, “Homelessness and Dual Diagnosis,” ibid., 1149–58; Jemelka, Ron, Trupin, E., and Chiles, J. A., “The Mentally Ill in Prisons: A Review,” Hospital & Community Psychiatry 40 (1989): 481–91Google ScholarPubMed. See also ibid., 43 (1992): 1253–54.
29. See Schwartz, Stuart R. and Goldfinger, S. M., “The New Chronic Patient: Clinical Characteristics of an Emerging Subgroup,” Hospital & Community Psychiatry 32 (1981): 473Google ScholarPubMed, and Barriers to Treating the Chronic Mentally Ill, ed. Meyerson, Arthur T. (San Francisco, 1987).Google Scholar
30. Department of Health and Human Services, Toward a National Plan for the Chronically Mentally Ill (Washington, D.C., 1980).Google Scholar
31. Goldman, Howard H. and Gattozzi, A. A., “Murder in the Cathedral Revisited: President Reagan and the Mentally Disabled,” Hospital & Community Psychiatry 39 (1988): 505–09Google ScholarPubMed, and “Balance of Powers: Social Security and the Mentally Disabled, 1980–1985,” Milbank Quarterly 66 (1988): 531–51.CrossRefGoogle Scholar
32. In the late 1980s and early 1990s both television and the printed media highlighted two cases in New York of homeless mentally ill persons (Joyce Brown [more popularly known as Billy Boggs] and Larry Hogue). Descriptions of these cases can be found in Isaac, Rael J. and Armat, V. A., Madness in the Streets: How Psychiatry and the Law Abandoned the Mentally Ill (New York, 1990), 256–60Google Scholar, 346–47
33. Pepper and Ryglewicz, Young Adult Chronic Patient, 121; Talbott, John A., “Deinstitutionalization: Avoiding the Disasters of the Past,” Hospital & Community Psychiatry 30 (1979): 623Google ScholarPubMed; Mechanic, David, “Correcting Misconceptions in Mental Health Policy: Strategies for Improved Care of the Seriously Mentally Ill,” Milbank Quarterly 65 (1987): 203–30CrossRefGoogle ScholarPubMed, and “Strategies for Integrating Public Mental Health Services,” Hospital & Community Psychiatry 42 (1991): 797–801.Google Scholar
34. Tessler, Richard C. and Goldman, H. H., The Chronically Mentally Ill: Assessing Community Support Programs (Cambridge, 1982)Google Scholar; Koyanagi, Chris and Goldman, H. H., “The Quiet Success of the National Plan for the Chronically Mentally Ill,” Hospital & Community Psychiatry 42 (1991): 901Google ScholarPubMed; Koyanagi, and Goldman, , Inching Forward: A Report on Progress Made in Federal Mental Health Policy in the 1980's (Alexandria, Va., 1991), 55–6.Google Scholar
35. Tessler, Richard C., Bernstein, A. G., Rosen, B. M., and Goldman, H. H., “The Chronically Mentally Ill in Community Support Systems,” Hospital & Community Psychiatry 33 (1982): 208–11Google Scholar; Koyanagi and Goldman, “The Quiet Success of the National Plan,” 904.
36. For a review of the Madison model see Kenneth S. Thompson, E. E. H. Griffith, and P. J. Leaf, “A Historical Review of the Madison Model of Community Care,” and Olfson, Mark, “Assertive Community Treatment: An Evaluation of the Experimental Evidence,” Hospital & Community Psychiatry 41 (1990): 625–41Google ScholarPubMed. See also Stein, Leonard I., ed., Innovative Community Mental Health Programs (San Francisco, 1992).Google Scholar
37. See Olfson, “Assertive Community Treatment,” 640.
38. Miles F. Shore and M. D. Cohen, “The Robert Wood Johnson Foundation Program on Chronic Mental Illness: An Overview,” Goldman, A. F. Lehman, J. P. Morrissey, S. J. Newman, R. G. Frank, and D. M. Steinwachs, “Design for the National Evaluation of the Robert Wood Johnson Program on Chronic Mental Illness,” and Goldman, Morrissey, and Ridgely, M. S., “Form and Function of Mental Health Authorities at RWJ Foundation Program Sites: Preliminary Observations,” all in Hospital & Community Psychiatry 41 (1990): 1212–30Google Scholar; David Mechanic, “Strategies for Integrating Public Mental Health Services,” 797–801.
39. Koyanagi and Goldman, “The Quiet Success of the National Plan,” 904.
40. The concept of “impure science” has been used by Silverstein, Arthur in his Pure Politics and Impure Science: The Swine Flu Affair (Baltimore, 1981).Google Scholar