A Brief History of the Deinstitutionalization Movement in the U.S.
For decades, states have been emptying their psychiatric hospitals. Between 1955 and 2000, the number of patients residing in long-term state mental hospitals declined from 559,000 to 54,000. Whereas the transition from institutional care to community-based care has been widely criticized and fraught with miscues, very few critics would advocate returning to the days of the asylum, which has become emblematic of past mistreatment of the mentally ill despite its high-minded origins.
During much of the 19th and early 20th centuries, the mental asylum was regarded as an integral component of the moral treatment of the mentally ill, the culmination of years of progressive-minded advocacy by activists including Dorothea Dix and Clifford Beers. It was certainly an improvement from the abuse and widespread use of physical restraints such as heavy arm and leg chains that characterized the treatment of the mentally ill in the 17th and 18th centuries. However, during the mid-19th century, local communities were expected to pay for the treatment that their ill and indigent received at large state hospitals, and were therefore reticent to admit them. For this reason, most mentally ill individuals remained in local almshouses for the poor and senile. That changed in the 1890s, when state care acts shifted financial responsibility from the communities to the state. With the allure of major cost savings, localities were quick to send their mentally ill, as well as the elderly, to mental hospitals. Senility was recast as a mental illness so that impoverished elderly, too, were sent en masse to these state-run hospitals. Populations in state hospitals swelled precipitously during this period, especially with patients requiring long-term care. By 1930, nearly 80 percent of all patients in mental hospitals in one state, Massachusetts, had resided there for more than five years.
The demise of the state-run mental institution has been a complicated affair, involving shifting ideologies as well as major advancements in medicine. By World War II, the role of mental hospitals in caring for patients with chronic mental illness, who often lived out their lives in psychiatric wards, lent itself to an increasing opinion by researchers and reporters that the hospitals were ill-suited places of recovery, a perception that was exacerbated by decades of anemic funding and deteriorating conditions. The alternative idea of treating mental illness closer to communities was bolstered by successes in treating active combat soldiers and returning them to their regiments during the war. In the 1950s, new pharmaceutical drugs, particularly thorazine, facilitated the shift to community care by reducing serious psychotic symptoms such as delusions and hallucinations, making care for the mentally ill appear more manageable. But as Gerald N. Grob argues, perhaps the driving force in laying the groundwork for deinstitutionalization was the growing role of the federal government in social welfare and health policy. In particular, Medicaid and Medicare, established in 1965, provided funding that allowed patients to be treated outside of state hospitals in nursing homes, hospitals and group homes. According to the National Institute of Mental Health, the percentage of inpatient, or institutional, treatment of psychiatric episodes declined from 77.4 percent in 1955 to 47.3 percent in 1968.