Deinstitutionalization and Mental Health in the U.S.

By Kimberly Tuttle (CMC’19)

Starting in the 1960s, the American government began to implement policies to deinstitutionalize the mentally ill. The deinstitutionalization movement was spurred by public outcry as a result of the exposure of the shortcomings of state-run “insane asylums” at the time. In 1955, the number of institutionalized mentally ill patients peaked at 558,000, or 0.03 percent of the population. Today, there are very few traditional “insane asylums” remaining and America’s deinstitutionalization remains one of the most controversial social experiments of modern history. The ongoing debate regarding mental health treatment in America sheds light onto the clear need for policy initiatives to provide meaningful mental health solutions to one of America’s most susceptible populations.

The asylum era began in the mid-1700s and was built upon societal notions of mental superiority. “The purpose of the earliest mental institutions was neither treatment nor cure, but rather the enforced segregation of inmates from society,” says Jeffrey Lieberman in Shrinks: The Untold Story of Psychiatry. Early institutions relied heavily on inhumane treatments in order to “cure the minds” of the patients. Common treatment practices, which are now considered torture methods by many, include the use of mechanical restraints, like straight jackets, leather wristlets, and waistcoats, as well as the use of shock therapy, lobotomies, food deprivation, simulated drowning, and forced cold and hot showers.

The 20th century sparked a clear shift in public opinion against old treatment methods. Americans recognized the fact that previous, moral-based mental treatments were overstretched, non-therapeutic, isolated, and cruel. Change, however, did not happen rapidly. At the beginning of the 20th century, increasing mental asylum admissions resulted in severe overcrowding and a new plethora of problems. Asylums in the 20th century became known for poor living conditions, lack of hygiene, and mistreatment of patients.

Pressure for institutional change mounted in the mid-20th century and American policymakers responded with the deinstitutionalization of American mental asylums. Between 1955 and 1994, roughly 487,000 mentally ill patients were discharged from state-run mental hospitals, lowering the patient total to 72,000. Due to this widespread deinstitutionalization, many patients were preemptively released to the public, where they often had no place to go and no resources to utilize.

Resources were inadequate even for those who remained in state-run mental hospitals. A 2012 report by the Treatment Advocacy Center found the number of psychiatric beds decreased 14 percent from 2005 to 2010. In 2010, there was a total of 50,509 state psychiatric beds; in 2016, there were only 37,679. While the number of psychiatric beds in America declined, however, the number of mentally ill people remained steady. According to the National Alliance on Mental Illness (NAMI), approximately one in 25 adults suffered from severe mental illness in 2015, totaling nearly 10 million people. This means that even if each state psychiatric hospital bed was in use, there would still be over 9 million untreated people suffering from severe mental illnesses in the U.S. Accordingly, a large portion of America’s mentally ill population was left bedless. The population of untreated, unsupported mentally ill people in America began to rise, resulting in a full-blown mental health crisis that became the center of most American news outlets in the early 2000s.

The discrepancy between deinstitutionalization and America’s fleeting mentally ill population as such has created a margin of society left vulnerable to homelessness and incarceration. NAMI reports that an estimated 26 percent of homeless adults staying in shelters suffer from serious mental illnesses, 46 percent from severe mental illnesses and/or substance use disorders, and that an estimated 20 percent of state prisoners and 21 percent of local jail prisoners have a recent history of mental illness.

There is a clear need for increased resources for America’s mentally ill population. District Attorney Mike Hestrin of Riverside County, California spoke on the mental health and homeless crisis that he is witnessing in his community and across the country. He explains, “What we were doing was putting drug addicts and mentally ill people in jail and prison, but that is not the right place for them. The problem, though, is that as a society, we don’t have anywhere to put them. Now, the street and the riverbed is where they are going.”

An unfortunate result of America’s deinstitutionalization is the endless cycle that mentally ill patients get trapped in that rotates them between the criminal justice system and the streets. While there are currently attempts being made by the criminal justice system to mitigate this problem through the use of mental health courts, homeless courts, and other collaborative court programs the mental health crisis is of much larger scale, with the number of mentally ill Americans reaching 44 million, and widespread institutional reform is needed in order to positively effectuate change.

Hestrin suggests, “Maybe we have to reimagine a type of rehabilitative center that still incorporates custody.” It is clear that America’s previous attempt to “cure” mental illness through the use of “insane asylums” was unsuccessful, yet complete deinstitutionalization has been unsuccessful for the mentally ill population as well. Now, it is the responsibility of policymakers to rethink a system that will fit the current needs of society without exploiting the vulnerable mentally ill population that has suffered through historical mistreatment by the American government.

Hestrin alludes to a system, similar to mental health court, that would give judges the ability to sanction mentally ill defendants with rehabilitative treatment in mental hospitals similar to the ones America previously utilized, though in partnership with the judicial branch that way a system of checks and behavioral standards could be put in place. In order to achieve success, professionals must come together across all disciplines—legal experts, law enforcement, medical professionals, social workers, and more—to conceptualize, construct, and implement a worthwhile solution that will help alleviate one of America’s most severe ongoing crises.

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