Deinstitutionalisation (or deinstitutionalization) 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. Deinstitutionalisation works in two ways: the first focuses on reducing the population size of mental institutions by releasing patients, shortening stays, and reducing both admissions and readmission rates; the second focuses on reforming mental hospitals' institutional processes so as to reduce or eliminate reinforcement of dependency, hopelessness, learned helplessness, and other maladaptive behaviours.[1]
According to psychiatrist Leon Eisenberg, deinstitutionalisation has been an overall benefit for most psychiatric patients, though many have been left homeless and without care.[2] The deinstitutionalisation movement was initiated by three factors:
A socio-political movement for community mental health services and open hospitals;
The advent of psychotropic drugs able to manage psychotic episodes;
A financial imperative to shift costs from state to federal budgets.[2]
According to American psychiatrist Loren Mosher, most deinstitutionalization in the USA took place after 1972, as a result of the availability of SSI, long after the antipsychotic drugs were used universally in state hospitals.[3]
According to psychiatrist and author Thomas Szasz, deinstitutionalisation is the policy and practice of transferring homeless, involuntarily hospitalised mental patients from state mental hospitals into many different kinds of de facto psychiatric institutions funded largely by the federal government. These federally subsidised institutions began in the United States and were quickly adopted by most Western governments. The plan was set in motion by the Community Mental Health Act as a part of John F. Kennedy's legislation[clarification needed] and passed by the U.S. Congress in 1963, mandating the appointment of a commission to make recommendations for "combating mental illness in the United States".[4]
In many cases the deinstitutionalisation of the mentally ill in the Western world from the 1960s onward has translated into policies of "community release". Individuals who previously would have been in mental institutions are no longer continuously supervised by health care workers. Some experts, such as E. Fuller Torrey, have considered deinstitutionalisation to be a failure,[5] while some consider many aspects of institutionalization to have been worse.
20th century
By the beginning of the 20th century, increasing admissions had resulted in serious overcrowding, causing many problems for psychiatric institutions. Funding was often cut, especially during periods of economic decline and wartime. Asylums became notorious for poor living conditions, lack of hygiene, overcrowding, ill-treatment, and abuse of patients; many patients starved to death.[7]
The first community-based alternatives were suggested and tentatively implemented in the 1920s and 1930s, although asylum numbers continued to increase up to the 1950s. The movement for deinstitutionalisation moved to the forefront in various countries during the 1950s and 1960s with the advent of chlorpromazine and other antipsychotic drugs.
The prevailing public arguments, time of onset, and pace of reforms varied by country.[7] In the United States, class action lawsuits and the scrutiny of institutions through disability activism and antipsychiatry helped expose poor conditions and treatment. Sociologists and others argued that such institutions maintained or created dependency, passivity, exclusion, and disability, which caused people to remain institutionalised. Rosenhan's experiment in 1973 "accelerated the movement to reform mental institutions and to deinstitutionalize as many mental patients as possible."[8]
A prevailing argument claimed that community services would be cheaper and that new psychiatric medications made it more feasible to release people into the community.[9] Mental health professionals, public officials, families, advocacy groups, public citizens, and unions held differing views on deinstitutionalisation.[10]
A key text in the development of deinstitutionalisation was Asylums by Erving Goffman.[11]
Consequences
Community services that developed include supportive housing with full or partial supervision and specialised teams (such as assertive community treatment and early intervention teams). Costs have been reported as generally equivalent to inpatient hospitalisation, even lower in some cases (depending on how well or poorly funded the community alternatives are).[7]
Although deinstitutionalisation has been positive for the majority of patients, it also has severe shortcomings.[12] Expectations that community care would lead to fuller social integration have not been achieved; many remain without work, have limited social contacts, and often live in sheltered environments.[13]
New community services are often uncoordinated and unable to meet complex needs. Services in the community sometimes isolate the mentally ill within a new ghetto, where service users meet each other but have little contact with the rest of the public community. It has been said that instead of "community psychiatry", reforms established a "psychiatric community".[7]
Existing patients are often discharged without sufficient preparation or support. A greater proportion of people with mental disorders become homeless or go to prison.[7] Families can often play a crucial role in the care of those who would typically be placed in long-term treatment centres. However, many mentally ill people are resistant to such help due to the nature of their conditions. The majority of those who would be under continuous care in long-stay psychiatric hospitals are paranoid and delusional to the point that they refuse help, believing they do not need it, which makes it difficult to treat them.[14]
