Learn how social factors promote mental health, influence the onset and course of mental illness, and affect how mental illnesses are diagnosed and treated. This course explores how our understanding of mental health and illness has been influenced by social attitudes and social developments in North America and around the world. The course begins by situating our contemporary mental health practices in historical context, then looks at different aspects of mental health, mental illness and mental health services and their connections to what’s going on in our social environment.
1.5 Deinstitutionalization
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From the course by University of Toronto
The Social Context of Mental Health and Illness
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From the lesson
Welcome and A Brief History of Madness
We begin with a quick orientation to the course and continue with our first lecture topic: A brief history of madness.
Meet the Instructors
Charmaine WilliamsAssociate Professor
Faculty of Social Work
So anti-psychiatry is in the background and a major change is about to happen in
mental health care. Deinstitutionalization.
Deinstitutionalization resulted in many people who'd been in long term patients
in psychiatric facilities being discharged into the community.
We often focus on that aspect of it, but deinstitutionalization also refers to the
fact that we began to shorten the length of stay that people had in hospitals
generally. And there was a decrease in the number of
beds that were available for psychiatric care.
The, the deinstitutionalization that I'm
describing really refers to the experience in North America.
In other parts of the world, there had been similar movements towards less
confining methods of providing care. However, not all countries had invested
as heavily in institution-based care as the US, Canada, and to some extent the
UK. So in other places,
deinstitutionalization was far less dramatic.
Also, it's important to note that while the number of people being
institutionalized for psychiatric care has dropped in much of the world. There
are some places where institutionalization has actually
increased after long histories of not having institutional based care.
So, let's talk about what happened in the Western context.
As we move into the early decades of the twentieth century, we had seen many
changes that opened up new options for dealing with mental illness.
the growing confidence in a scientific model for dealing with mental health
problems had shifted the emphasis in care from isolating people with mental
disorders to treating them. This change was signaled by the shifting
nomenclature for mental health care institutions, now called hospitals rather
than asylums. And, starting around the 1950s, new
medical treatments became available, drugs like antipsychotic medications,
antidepressants, mood stabilizers, and major tranquilizers offer the possibility
of reducing psychiatric symptoms and enabling people to function outside of
hospitals. Another important development was the
introduction of psychotherapies as a treatment for mental illness.
In Europe, pschotherapy and especially psychoanalysis had been used for a long
time, but the wide use of these psychotherapies came later in North
America and the 50s and 60s saw much more widespread use of psychodynamic and other
therapies to treat people, somtimes independently or as an addition to
treatment with medications. So those, were some of the positive
things going on that made deinstatualization of the mental health
care system possible. At the same time, there were also some
negative things happening, that would push the system towards
deinstitutionalization, Some of those you've already heard about
in the anti-psychiatry lecture, so we knew, we know that there where
treatments going on at the time that were actually quite harmful to patients and
that was being brought to the attention of the public.
even we've mostly focused on the shock therapies and on lobotomies, but as I
already said, even the the medications themselves could be problematic and
certainly psycho ex-patients that were talking about their experiences in the
mental healthcare system were quite vocal about what they saw as the harm that
those treatments had done to them. I've also already mentioned other abuses
within psychiatry that were reaching public attention.
one that is particularly relevant in Canada is the work of Dr.
Ewen Cameron, who in the 50s was exposing psychic, psychiatric patients to LSD and
high levels of electroshock therapy as part of mind control experiments for the
CIA. These patients did not consent to this
and suffered significant damage from it, and unfortunately, this work was repeated
in other parts of the world. so internationally there were stories
circulating about psychiatrists and psych, psychiatric hospitals that really
diminished the trust that the public had in mental health care facilities.
This together with another period of declining investment in psychiatric
institutions certainly helped to set the stage for transferring the care of people
with mental illnesses away from such places.
So deinstitutionalization, you see, refers to the shifting of care for people
diagnosed with mental illnesses from psychiatric facilities where they were
receiving long term care to receiving care in the community.
The vision is that these former patients now better able to function because of
the availability of new treatments that they should be capable of living
independently in the community. Deinstitutionalization was the result of
the conversion conversions of forces and events.
we conventionally refer to, to it being stimulated by the introduction of new
drugs as I've already mentioned. and this was especially liberating for
people with psychotic disorders like schizophrenia, because they had been a
group of patients often left to languish, languish in psychiatric institutions.
There was also a lot of legal advocacy that prompted deinstitutionalization by
asserting that patients had the right to be treated using the least restrictive
alternatives for care. The 50s and 60s was a time of important
legislation around the conditions under which people could be confined to
psychiatric institutions and they laid down early versions of mental health acts
that would determine involuntary treatment was only permissible when
someone was a danger to themselves or other.
activism was also important in pushing towards the institutionalization because
of the anti psychiatry movement, the consumer survivor movement, the
disability rights movement. All in various ways they criticized in,
institution-based psychiatric care and advocated for the self-determination of
people diagnosed with mental illnesses. So, you'll see these kind of numbers all
over the internet in terms of like, if we think about in the U.S.
in 1955, there were almost 600,000 people institutionalized and there was a
population of a 165 million. Then we go to 1998 where there are now
only about 60,000, so it's dropped by 10% at a time when the
population has increased quite a bit. So there are some other explanations for
why deinstitutionalization was able to happen at that time.
There are some that would suggest that there were economic reasons why there was
a deinstitutionalization. as I've already mentioned, the system was
in another period of withdrawn investment and the cost for running institutions had
risen, not only because everything was more expensive, but because they could no
longer rely on unpaid patient labor to make the places run.
Some suggest that discharging patients from institutions was a move to save
money. It was much cheaper to neglect them in
the community than to take care of them in institutions.
Now this is an argument that doesn't really hold up very well if you look at
it carefully, because community care is not actually
less expensive than institution, institution-based care.
but but certainly there are some people who believe that that is one of the
motivations is that it was just better for the bottom line.
There's another set of arguments that we'll talk about,
the shift to an emphasis on accute care instead of chronic care.
So there was a shift of resources, so that instead of devoting most of our
energy to patients with chronic and long term illnesses there was more attention
being paid to dealing with accute care and treatment in general hospitals and
primary health care settings. So this was also for the signaling of
shift in the, in the expansion of the scope of mental health practice.
so it was no longer just concerned with people who were severely ill and, and
significantly disabled, but also with people who are at, who are
at other places on the spectrum. So there definitely was a shift to
attention for acute care and that certainly
would have contributed to more of an emphasis on services in the community
rather than institutions. Another important change was the shift
toward a biopsychosocial model of mental health care that suggested psychological
and psychosocial treatments were as important as medical and pharmacological
treatments. So the increasing use of psychotherapy
and psychosocial rehabilitation, which I will talk about more in the next section
really meant that people needed to be out in the community,
because, actually being in the community was being part of, was part of the
treatment. So again,
having other options for treatment and seeing community placement as part of
that treatment was another reason why deinstitutionalization, was poised to
happen. Now, Randall Krieg in a paper that I've,
we'll attach in the resource section, sorry, I'll attach the reference for it
in the resource section, took a look at deinstitutionalization using what he
called a stakeholder analysis in an attempt to explain why
deinstitutionalization is something that most people agree was a positive change
but really has such an ambivalent, has been such an ambivalent experience.
So, in his paper, he suggests that from the perspective of patients or consumers
of psychiatric services, deinstitutionalization was a very
positive move away from a paternalistic system in which almost everyone is
assumed to be a better judge of their best interests than they were to a system
that was prepared to engage with them based on their self-determination and so
pre-existing institutionalization as mostly a win for consumers of psychiatric
services. He is less positive about its effects for
the community that ended up receiving the institutionalized patients.
He asserts that when patients were no longer institutionalized, communities
became exposed to threats from which the institutions had previously insulated
them. He describes ex-patients as a threat to
the security and stability of communities and feels that community members being
exposed to homelessness, for example, is a negative effect of
deinstitutionalization. Now, I'm not in complete agreement with
this because first, the belief that having people with mental illness in the
community increases violence and instability really doesn't hold up if you
look at the research. In fact, people with mental illnesses are
far more look like, far more likely to be victims of violence than members in the
general public. Also, the communities exposure to
homelessness is not a problem that really originates with ex-patients.
It's a problem that originates with inadequate housing resources and lack of
access to affordable housing and those problems affect many groups, frankly any
group that is low income. So while I would not deny that these
problems exist, I do object to them being attached to
people diagnosed with mental illness as if they are the entire or exclusive cause
of them. I find it easier to agree there's a
suggestion that community members have been forced to face tough questions about
what is their obligation to care for people among them,
since institutionalized care was one way of removing them from that
responsibility. You may remember that the Canadian
National Committee on Mental Hygiene exhibit was very much about telling the
community. You don't have to worry about this,
we'll take care of it, we'll take it far away from you and your
neighborhood. So once the institutions started to close
down and a number of hospital beds were reduced, people in communities were
really forced to consider what support they were willing to extend to these
members of their communities. Finally, the community is also affected
by the fact that there is no cost saving in transferring institutional care to the
community. Care and support services simply need to
be transferred to other organizations and what we have seen is that a wider range
of services required, is required, so the health care system
cannot manage the needs of people with mental illnesses without supporting
collaboration from other systems like housing, education, employment,
family services, and social services. Krieg also takes a look at family members
and talks about an ambivalent experience for them,
which we're going to talk about when we have our lecture about families and
mental illness in more detail. But certainly deinstitutionalization
meant that care was taken up by family members and not necessarily with enough
support. And there's a huge literature that talks
about the burden of being a caregiver for somebody who is diagnosed with a mental
illness. And we, we do of course, want to bounce
that against the fact that family members have been cut off from their loved ones
through much of the history of mental health care.
And so there was some burden, but there was also some value for some people in
having their family members back with them and being sort of invited into that
circle again. But yes, an ambivalent experience.
So maybe it's hard for us to know completely what motivated the
deinstitutionalization, but I think it's unquestionable that
challenging the system to provide care in the least restrictive means was an
important gain for human rights as was the development of the legislation that
increased accountability around the reasons for involuntary admission to
psychiatric institutions, and increase the accountability for insuring the
patients participated in treatment under conditions of self-determination and
informed consent. The problem with deinstitutionalization
was that it happened before community services were in place to replace the
institutions. We locate deinstitutionalization in the
1950s, but they had actually started large scale discharging of patients from
institutions as early as a decade before that.
But, resources stayed with the institutions, even though the patients
were leaving, and I remember that even when I started working in psychiatry in
the 90s, early 90s,90s, yes.
We were still talking about the fact that a lot of the money and the resources were
still with hospitals, when they had been promising and promising, basically since
the 50s, that it was going to be shifted to the community.
So the consequences of that were that people who needed treatment weren't
getting it. Others were getting treatment, but not
really getting full benefits from it. And in the community environment, there
were ongoing symptoms that made it difficult to cope and the, these patients
did not have the predictable controlled environment of a hospital to make that
easier. Many patients weren't able to sustain
themselves in independent living situations, and so, and they needed
support of housing that simply wasn't available.
This contributed to the homelessness that Krieg talks about.
This also contributed to criminal justice involvement for people with mental
illnesses. There are many studies that show large
percentages of people incarcerated in the crimical, criminal justice system have
diagnosable mental illnesses. Certainly mental illness doesn't
discriminate and people who commit crimes can have a mental illness as well,
but we believe that many of these people end up in trouble with the law because of
inadequately treated mental illnesses. If they were well, would they have gotten
into situations that led to their incarceration?
It's not an easy question to answer, but it's one that we certainly have to
ask. Krieg also alludes to the burden on
families and communities and lack of institutional care and community services
has certainly increased the amount of labor that has been required of, of
family members. we'll talk more about this in the week on
families and mental illness, but there's an extensive literature that
takes about, talks about the toll that care giving takes.
And the feelings that families have that the system really abandoned them and
their relatives with diagnoses. Finally, not everyone is enthusiastic
about the benefits that deinstitutionalization has had for people
who are diagnosed with mental illness. Many patients benefit from
community-based care, primary health base care,
but there also many for whom this level of care is inadequate. Some suggest that
in an extreme sling from instutionalization to
deinstutionalizations, these patients paid the cost, becausee they now
experience longer illness, more frequent illness and are more vulnerable to things
like, violence in a community, and exploitation, because they are simply not
in the protected circumstances that they once had.
Another issue too, is the rising substance abuse that we see in people who
are diagnosed with mental illnesses, which is another way that, that people
see them being increased, increasingly exposed to vulnerability.
Another troubling aspect of deinstitutionalization is that many
people who are diagnosed with mental illness live in our communities facing
social isolation, stigma, and discrimination.
So this isn't really something that, that originated with
deinstitutionalization, but the transfer to the community results
in this becoming a part of the daily experience of these people.
So, for deinstitutionalization to work, we really needed adequate community
services and that's why we'll be talking about community-based mental health care
in the next segment.
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