What has been learned from the successes and failures of deinstitutionalization? Since the 1950s it has been solid practice in the United States, and some Washingtonians believe it’s caused the concept of mental health to become as distorted as some of the severe illnesses found in its field of study.
Deinstitutionalization is the policy of moving severely mentally ill people out of psychiatric hospitals and large state institutions, and then closing part [or all] of those institution. Dr. Mary Conrad, a psychiatrist in private practice in Chevy Chase, MD, believes this procedure has been a major contributing factor to the mental illness crisis that we currently face.
“In the beginning people were moved from decent institutions to nothing at all,” she said. “Furthermore, it’s gone from an idea to a disastrous movement where people that needed to be in the safety of a mental institution, were denied the right – unless someone could pay for it, outside of the government.”
Deinstitutionalization was established in 1955, during the Eisenhower administration. The process also brought the introduction of chlorpromazine, commonly known as Thorazine. Thorazine was the first effective antipsychotic medication, and received a major impetus ten (10) years later with the enactment of federal Medicaid and Medicare.
The concept of deinstitutionalization comes in two parts: the moving of the severely mentally ill out of the state institutions, and the closing of part or all of those institutions. The former affected people who are already mentally ill. The latter affected those who were not diagnosed (but possibly still needed to be hospitalized).
“The magnitude of deinstitutionalization of the severely mentally ill qualifies it as one of the largest social experiments in American history,” said Washington, D.C. activist Charles McRae, who lives in southeast D.C. McRae is a retired social worker who has worked for the mentally ill as an advocate.
By changing the classification of mentally ill and promising of improving some structures that were falling apart, became common place. During its inception in 1955, there were 558,239 severely mentally ill patients in the nation's public psychiatric hospitals. In 1994, this number had been reduced to 71,619. However, the census of 558,239 patients was in relation to the United States total population (at 164 million).
Deinstitutionalization varied from state to state. Rhode Island, Massachusetts, New Hampshire, Vermont, West Virginia, Arkansas, Wisconsin, and California all had/have effective deinstitutionalization rates of over 95 percent. Rhode Island's rate is over 98 percent, meaning that for every 100 state residents in public mental hospitals in 1955; fewer than 2 patients are there today. On the other end of the curve, Nevada, Delaware, and the District of Columbia have effective deinstitutionalization rates below 80 percent.
The people who were deinstitutionalized were severely mentally ill. Between 50 and 60 percent of them were diagnosed with schizophrenia. Another 10 to 15 percent were diagnosed with manic-depressive illness and severe depression. An additional 10 to 15 percent were diagnosed with organic brain diseases -- epilepsy, strokes, Alzheimer's disease, and brain damage secondary to trauma. The remaining individuals residing in public psychiatric hospitals had conditions such as mental retardation with psychosis, autism and other psychiatric disorders of childhood, and alcoholism and drug addiction with concurrent brain damage. ]
They were deemed well enough to be released, or to be transferred to home care. People were returning to their homes around the District; some with true understanding with what was going on. Over time some became homeless and were devoid of "dignity" or "integrity of body, mind, and spirit." "Self-determination" often meant pan-handling, homeless shelter, or sleeping in the parks (like the one across from Union Station). Sadly, those who were not taking their medications at proper intervals were found themselves before a judge, in a jail cell, or a terror-filled existence plagued by both real and imaginary enemies.
John P., a returning citizen who’s also in recovery, is concerned about how those with mental disabilities are being treated in prison.
“When I was locked up in the 80s, prison was a terrible place for people with mental disabilities,” he said at a recent discussion on mental health in D.C. “People were just thrown amongst the worst of the worst, and had them heavily over-medicated. I had heard of and seen some terrible things”
Another returning citizen who spent three years at Rivers Correctional in Winton, North Carolina, Miguel Salazar, said medication control is heavily needed at the private prison.
“There are lots of Washington residents at Rivers Correctional who need proper mental health care. When I was there, there was only one actual psych doctor for all of us inmates. I’d go to pill call and took my anti-depression meds, but there were a lot of guys who weren’t taking their meds. “He added that guys were placing the pills under their tongue and walking away and sold them to other inmates.
Salazar added, “Prison is no place for a person with severe mental health issues.”
How many people with severe mental illnesses are in jails and prisons on any given day? If such illnesses are defined to include only schizophrenia, manic-depressive illness, and severe depression, then approximately 10 percent of all jail and prison inmates appear to meet these diagnostic criteria. The most recent data available in 1995 indicated there were 483,717 inmates in jails and 1,104,074 inmates in state and federal prisons in the United States, a total of 1,587,791 prisoners.25 If 10 percent of them are severely mentally ill, that would be approximately 159,000 people. It is also likely that the mentally ill often rotate back and forth between being homeless and being in jails or prisons.
“Deinstitutionalization doesn't work,” said Randal Jackson, a Master’s student at the University of the District of Columbia. “It doesn’t work because all we’re doing is switching places. Instead of being in hospitals, people are placed in jails.”
Some social scientists believe deinstitutionalization has helped create the mental illness crisis by discharging people from public psychiatric hospitals without ensuring that they received the medication and rehabilitation services necessary for them to live successfully in the community.
“I’m all for lessening the number of people in prison, but deinstitutionalization caused big problems because, people weren’t just removed; people were removed and the space was discontinued,” Jackson added. “That means the people who needed the space the most, the severely mentally ill, couldn’t get it – and that process continues today.”
Consequently, approximately 2.2 million severely mentally ill people do not receive any psychiatric treatment.
Jackson said that deinstitutionalization was based on the idea that severe mental illness should be treated in the least restrictive setting.
President John F. Kennedy's 1963 Community Mental Health Centers Act accelerated the trend toward deinstitutionalization with the establishment of a network of community mental health centers. In the late 1970s, President Jimmy Carter's Commission on Mental Health mentioned "the objective of maintaining the greatest degree of freedom, self-determination, autonomy, dignity, and integrity of body, mind, and spirit for the individual while he or she participates in treatment or receives services."
Court Services Office and Supervision Agency’s (CSOSA) blog released an article in 2008 entitled Managing the Mentally Ill Offender in Washington, D.C. A portion of the article says, “…It’s difficult to operate within a purely medical model when a mentally ill offender becomes violent or disruptive and threatens the safety and security of the institution. Most correctional professionals have witnessed nurses and psychologists attempting to “talk down” an inmate after a verbal and near-physical encounter with staff or fellow inmates. Seething with emotion and ready to burst, the mentally ill inmate may sometimes stay in that agitated condition for hours at a time while the realities of prison continues to surround them…”
Jackson, who has read the article, agrees.
“What CSOSA says is totally correct. Many of the correctional personnel have little or no real training in handling an angry inmate who has a several mental illness,” he added. Jackson also mentioned that these staffers are used to using aggression to resolve the issue, which only makes the situation worse.
Organizations like University Legal Services are doing all they can to aid the mentally ill that are incarcerated or have been released and need serious attention.
CSOSA’s blog notes that there are thirty CSOs (Community Service Officers) and supervisors who staff their mental health teams. Their mental health offenders are “assigned to this specialized unit via a D.C. Superior Court or U.S. Parole Commission order; offenders assigned to another unit may also be referred by the CSO for evaluation.” The organization has existing contracts with psychologists who work tirelessly at conducting assessments of every referred offender.
“Once the offender’s mental health condition is controlled, he or she can benefit from other CSOSA services, such as job training, drug treatment, anger management or a faith-based mentor,” mentioned on CSOSA’s website.
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