Deinstitutionalization—the movement of mentally disabled people from mental institutions into a community- or family-based environment—is a concept that transformed in a generation from a solution to a problem. Introduced in the early 1960s as a way to reduce societal reliance on state institutions, the policy itself became a problem by the early 1980s. Increases in homelessness, poor community services for the mentally ill, the placement of the chronically mentally ill in nursing homes, the increase in the mentally ill in jails and prisons, and a general increase of incivility in large cities were all seen as consequences of deinstitutionalization. For many, the reform caused more problems than it solved.
The United States, by the mid-20th century, had become a country reliant on “total institutions” to control and treat deviance and dependency. State mental hospitals counted more than a half million patients and had long waiting lists in most states. Institutions for children dominated care for dependent and neglected minors. Prisons were the answer to criminality. Although the poorhouses of the 19th century had disappeared, their replacement—public housing projects and federal welfare programs—segregated the poor in minority communities. Started during the second quarter of the 19th century, these public institutions lost their legitimacy as a reasonable way to care for the needy and troubled. They were expensive, overcrowded, and generally seen as failures. They neither rehabilitated nor protected. That consensus led to new ideas about care and containment. Moral entrepreneurs from both the left and the right stepped in with proposals to close institutions. Scholarship emphasis on institutions shifted from seeing them as agencies of reform to seeing them as producing the very problems earlier reformers thought they would fix. If institutions were causing the problems they were supposed to ameliorate, then closing those institutions, or at least reducing the reliance on them, would improve the situation greatly. Deinstitutionalization was the name given to those efforts.
By the 1980s deinstitutionalization had become a bad word. Officials emptied the mental hospitals and closed down children’s institutions. The median length of stay in state mental hospitals dropped by almost 44 percent during the 1970s. Between 1974 and 1984 the number of beds in state mental hospitals dropped by more than 58 percent. But community mental health services intended to replace mental hospitals and foster care in place of children’s institutions failed to improve conditions for mentally ill or dependent children. Journalistic reports revealed that many of the mentally ill were living on the streets, and children in foster care were trapped in a permanent limbo. Homelessness increased 300 percent in the 1980s, and fear of the mentally ill intensified as involuntary commitment receded. Prison populations skyrocketed, and the mentally ill filled the jails. Nursing homes became repositories for the chronically mentally ill in many states. By the 1990s few spoke of deinstitutionalization as a remedy, and most spoke of it as a problem. Little could be done to reverse the trends, though. Case law made reinstitutionalization a legal impossibility. The Supreme Court limited the use of institutions, and state courts were reticent to reverse this trend away from exclusion and confinement. By the 21st century, society had transitioned into a world of care and containment that included the deviant in society (with prisons as the notable exception).
Nevertheless, deinstitutionalization left society with a new set of serious and persistent problems. Whereas some scholars could look back and see progress, many citizens could only see communities that did not have the tools to care for and contain the chronically mentally ill. For them, deinstitutionalization failed to protect society from the troubled and troubling. With involuntary commitment greatly restricted and most state mental health systems committed to community care, even the most difficult mentally ill persons were assigned community care or no care at all. After a quarter century of experience, few would call it a success. Yet, the society seemed incapable of moving beyond the rhetoric of inclusion and the reality of weak social control capacity.
From the variety of explanations for this turn of events, some argue that deinstitutionalization was flawed in its conceptualization. Built on symbolic interactionist theory of the self and its production, the very idea misspecified the source of the deviance and the process that brought it into being. Many important works on deinstitutionalization assumed that mental illness was less a disease and more a learned social role. Given that fundamental theoretical mistake, they argued, the policies that followed could not help but be flawed. Acting mentally ill did not disappear when the socializing institutions that taught the role disappeared. Others felt that the theory was correct but that the implementation was woefully inadequate. Most mental health care is provided by state systems. Although the 1970s saw a rapid decline in patient censuses at state hospitals, the saved dollars were slow in being transferred to community services. The community services that developed were poorly integrated, as most states relied on private organizations to deliver community care. The idea of deinstitutionalization was solid; the implementation was deplorable. States failed to put the resources into the new community services, and the results were unsurprisingly devastating.
Deinstitutionalization is part of a major transformation of social control strategies that occurred in the last quarter of the 20th century. Desegregation of schools and deconcentration of public housing combined with deinstitutionalization of mental hospitals to absorb deviant and dependent populations back into civil society. The exclusion that was the hallmark of institutionalization was replaced by the push for inclusion. Stimulated by the civil rights movement and a desire to correct the abuses of the institutional system of care, the push to mainstream those on the fringes of society has won the day. Today the deviant are hidden away downtown as opposed to out of town in institutions. But the mentally ill and other deviant groups did not disappear. Nothing in the move to inclusion reduced the number of people who experience mental illness or the ravages of poverty and racism. Today, they are hidden among us waiting for a new generation of social problem researchers to tear away the camouflage and expose the reality of a deinstitutionalized system of care.
- Lewis, Dan A., Stephanie Riger, Helen Rosenberg, Hendrik Wagenaar, Arthur J. Lurigio, and Susan Reed. 1991. Worlds of the Mentally III: How Deinstitutionalization Works in the City. Edwardsville, IL: Southern Illinois University Press.
- Winerip, Michael. 1994. 9 Highland Road. New York: Pantheon.
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