Psychiatry and Deinstitutionalization
Psychiatry and Deinstitutionalization
There is an agreement that about 2.8% of the US adult population suffers from severe mental illness. The most severely disabled have been forgotten not only by society, but by most mental health advocates, policy experts and care providers. Deinstitutionalization is the name given to the policy of moving severely mentally ill patients out of large state institutions and then closing the institutions as a whole or partially. Deinstitutionalization is a multifunctional process to be viewed in a parallel way with the existing unmet socioeconomical needs of the persons to be discharged in the community and the development of a system of care alternatives (Mechanic 1990, Madianos 2002). The goal of deinstitutionalization is that people who suffer day to day with mental illness could lead a more normal life than living day to day in an institution. The movement was designed to avoid inadequate hospitals, promote socialization, and to reduce the cost of treatment.
Many problems developed from this policy. The discharged individuals from public psychiatric hospitals were not ensured the medication and rehabilitation services necessary for them to live independently within the community. Many of the mentally ill patients were left homeless in the streets. Some of the discharged patients displayed unpredictable and violent behaviors and lacked direction within the community. A multitude of mentally ill patients ended up incarcerated or sent to emergency rooms. This placed a huge burden on the jail systems. Communities were not the only ones to suffer. Those who suffered with mental illness were the ones who were ultimately affected. The stereotypes attached to mental illness were enough for some to not get the appropriate help that they needed. Often times, the communities would not get involved, discarding those who suffer with mental illness. Commonly, those with mental disorders do not have the means or abilities to take care of themselves, relying heavily on state or local centers for help.
If the centers are not there to help, where are they to go? Because of deinstitutionalization, there are those, who live on the streets, are put in jails, or are left to fight for their lives alone. In the United States in the nineteenth century, hospitals were built to house and care for people with chronic illness, and mental health care was a local responsibility. Individual states assumed primary responsibilities for mental hospitals beginning in 1890. In the first part of the twentieth century many patients received custodial care in state hospitals. Custodial care means care in which the patient is watched and protected, but a cure is not sought. After the National Institutes of Mental Health was founded, new psychiatric medications were developed and introduced into state mental hospitals beginning in 1955.
The new medicines brought hope. President John F. Kennedy’s 1963 Community Mental Health Centers Act promoted and sped up the trend toward deinstitutionalization with the establishment of a network of community health centers. In the 1960s, when Medicare and Medicaid were introduced, the federal government took on a share of responsibility for mental health care costs. That trend continued into the 1970s with the placement of the Supplemental Security Income program in 1974. State governments promoted and helped accelerate deinstitutionalization, especially of the elderly. Deinstitutionalization is directly linked with the state and the financial support of the program. In several countries the shift from the welfare state to the caused dramatic negative impact in the organization of the delivery of effective and adequate mental health care for the unstable low class mentally ill individuals. As hospitalization costs increased, both the federal and state governments were motivated to find less expensive alternatives to hospitalization.
The 1965 amendments to Social Security shifted about 50 percent of the mental health care costs from states to the federal government. This motivated the government to promote deinstitutionalization. In the 1980s, managed care systems started to review the use of inpatient hospital care for patients that suffered with mental health issues. Public frustration along with concern and private health insurance policies created financial bonuses to admit fewer people to hospitals and to discharge inpatients quicker, limit the length of patient stays in the hospital, or to produce less costly forms of patient care. Deinstitutionalization also describes the adjustment process that those with mental illnesses are removed from the effects of living in a mental health facility. Since people may become accustomed to institutional environments, they sometimes act and behave like they are still living within the institution; therefore, adjusting to life outside of an institution can be very difficult.
Deinstitutionalization gives those living with mental illness the chance to regain freedom. With the assistance of social workers and through psychiatric therapy, former inpatients can adjust to everyday life outside of institutional walls. This aspect of deinstitutionalization promotes recovery for the many that have been put into different group homes and those who have been made homeless. A number of factors led to an increase in homelessness, including macroeconomic shifts, but researchers also saw a change related to deinstitutionalization. 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. The homeless mentally ill represented an immediate challenge to the mental health field in the 1980s. Those homeless who have histories of being institutionalized stand as reminders of the cons of deinstitutionalization.
Mentally ill homeless persons who never have been treated often speak of unfulfilled promises of community-based care after deinstitutionalization. Homelessness and mental illness are social problems, very similar in some ways, but very different respectively. Patients were often discharged without sufficient preparation or support. A greater number of people with mental disorders became homeless or went to prison. Widespread homelessness occurred in some states in the USA. There are now about one million homeless chronically mentally ill persons in all the major cities of USA. Much has been learned during the era of deinstitutionalization. Many of the homeless mentally ill feel alienated from both society and the mental health system, that they are fearful and suspicious, and that they do not want to give up what they see as their own personal sense of independence, living on the streets where they have to answer to no one.
They may be too severely mentally ill and disorganized to respond to any efforts of help. They may not want a mentally ill identity, may not wish to or are not able to give up their isolated life-style and their independence, and may not wish to acknowledge their dependency. Community services that developed included housing with full or partial supervision in the community. Costs have been reported to be as costly as inpatient hospitalization. Although reports show that deinstitutionalization has been positive for the majority of patients, it also has been ineffective in many ways. Expectations of community care have not been met. It was expected that community care would lead to social integration. Many discharged patients remain without work, have limited social contacts and often live in sheltered environments.
New community services were often unable to meet the diverse needs. Services in the community sometimes isolated the mentally ill within a new “ghetto”. Families can play a very important role in the care of those who would typically be placed in long-term treatment centers. However, many mentally ill people lack any such help due to the extent 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 and do not believe they need it, which makes it difficult to treat them. Some other studies pointed out the harmful effect on mental health from other situations related to economy, such as unemployment, community’s economic hardship and social disruption as well as criminality and violence. Moving mentally ill persons to community living leads to various concerns and fears, from both the individuals themselves and the members of the community.
Many community members fear that the mentally ill persons will be violent. Despite common perceptions by the public and media that people with mental disorders released into the community are more likely to be dangerous and violent, a study showed that they were not more likely to commit a violent crime more than those in the neighborhoods. The study was taken in a neighborhood where substance abuse and crime was usually high. The aggression and violence that does occur is usually within family settings rather than between strangers. Despite the constant movement toward deinstitutionalization and the closing of institutions, deinstitutionalization continues to be a controversial topic in many different states. Many have researched and examined the pros and cons along with the relative risks and benefits associated with institutional and community living.
Many studies have examined changes in adaptive or challenging behavior associated with being moved from an institution to a community setting. Summaries of the research indicated that, overall, adaptive behavior were almost always found to get better with movement to a community living environment from institutions, and that parents who were often opposed to deinstitutionalization were almost always satisfied with the results of the move to the community after it occurred (Larson & Lakin, 1989; Larson & Lakin, 1991). A recent study showed that certain behavior skills found that self-care skills and communication skills, academic skills, social skills, community living skills, and physical development improved significantly with deinstitutionalization (Lynch, Kellow & Willson, 1997).
It becomes apparent that deinstitutionalized persons with serious mental illness in many places across the world are subject to a plethora of health and social problems and are facing significant difficulties in the process of accessing health care services. In the USA people with severe mental illness due to their social class and financial stability, are subject to underfunded health d mental health care systems. While attempting to properly care for mentally ill persons, the health care system is trying to overcome a wide range of obstacles, such as lack of reimbursement for health education and family support, inadequate and under skilled case of management services, poor coordination and communication between services and lack of treatment for co-occurring psychiatric and substance abuse disorders.
Last but not least, deinstitutionalization was often linked with the community’s reaction and negative attitudes, prejudice, stereotypes, stigma and discrimination against the community placement of persons with serious mental illness (Matschinger and Angermeyer 2004). However, stigma and negative attitudes can always be changed if people are willing to change their beliefs and if appropriate and effective community mental health care efforts are made in regards to helping persons living day to day with mental illness. Deinstitutionalization was not only attempted in the USA but it was attempted in countries such as Italy, Greece, Spain, and other Eastern countries.
In those countries deinstitutionalization was shown to be successful when psychiatric reform was a priority and was completed with an effective system of community based services and sufficient financial care. This means that the very complex process of deinstitutionalization is a step by step multidimensional process. Deinstitutionalization attempts to focus on the individual’s life needs, including the continuance of treatment, health and mental health care, housing, employment, education and a community support system that works. If family exists and is involved in the life of the mentally ill person, the state eliminates the burden of care. “The final goal is the community autonomous tenure of the suffering individual and his/her integration, in a status of full social and clinical recovery (Matschinger and Angermeyer 2004).
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University/College: University of California
Type of paper: Thesis/Dissertation Chapter
Date: 10 January 2017
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