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. Kennedys 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 patientsparticularly the severely mentally-
ill, racial minorities, and the economically disadvantagedreintegration 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 Cuckoos 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 nations 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 todays 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 hospitalswhich 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.
Works Cited
Comer, R. J. (2007). Abnormal Psychology. 6th ed. New York: Worth Publishers.
Gilligan, J. (2001). The last mental hospital. Psychiatric Quarterly 72(1): 45-61.
Horowitz, A. V. (2002). Creating Mental Illness. Chicago: University of Chicago Press.
Markowitz, F. E. (2006). Psychiatric hospital capacity, homelessness, and crime arrest
rates. Criminology 44: 45-72.
Morrissey, J. P., & Goldman, H. H. (1984). Cycles of reform in the care of the chronically
mentally-ill. Hospital and Community Psychiatry 35: 785-793.
Navasky, M., & OConnor, K. (Writers & Directors). (2005). The New Asylums. In D.
Fanning Frontline. Boston: WGBH.
Rothman, D. J. (2002). Discovery of the Asylum: Social Order and Disorder in the New
Republic. Hawthorne: Aldine de Gruyter.
Sue, D., Sue, D. W., & Sue, S. (2010). Understanding Abnormal Behavior. 9th ed.
Boston: Wadsworth.
Teplin, L. A., & Pruett, N. S. (1992). Police as streetcomer psychiatrist: Managing the
mentally-ill. International Journal of Law and Psychiatry 15: 139-156.
Torrey, F. E. (1995). Jails and prisons: Americas new mental hospitals. American
Journal of Public Health 85(12): 1611-1613.
Wang, P. S., Demler, O., & Kessler, R. C. (2002). Adequacy of treatment for serious
mental illness in the United States. American Journal of Public Health 92(1): 92-98