Deinstitutionalisation (or deinstitutionalization) is the process of replacing long-stay psychiatric hospitals with less isolated community mental health services for those diagnosed with a mental disorder or developmental disability. In the late 20th century, it led to the closure of many psychiatric hospitals, as patients were increasingly cared for at home or in halfway houses, clinics and regular hospitals.
Deinstitutionalisation works in two ways. The first focuses on reducing the population size of mental institutions by releasing patients, shortening stays, and reducing both admissions and readmission rates. The second focuses on reforming psychiatric care to reduce (or avoid encouraging) feelings of dependency, hopelessness and other behaviors that make it hard for patients to adjust to a life outside of care.[1]
The modern deinstitutionalisation movement was initiated by three factors:
The movement to reduce institutionalization was met with wide acceptance in Western countries, though its effects have been the subject of many debates. Some experts, such as E. Fuller Torrey, have argued that deinstitutionalization was a mistake,[3] while others, such as Thomas Szasz, argue it did not provide enough freedom for patients.[4] Others have argued that it was an improvement on the system that existed before. Psychiatrist Leon Eisenberg has argued that it has generally been beneficial for psychiatric patients, while noting that some were left homeless or without care.
- A socio-political movement for community mental health services and open hospitals;
- The advent of psychiatric drugs able to manage psychotic episodes;
- Financial imperatives (in the US specifically, to shift costs from state to federal budgets)[2]
In the US, deinstitutionalization was carried out on a large scale in the 1970s. These released patients have become emblematic of the homeless population.
Mental hospitals once had the reputation of being dungeons for the insane. A new hope arose in the 1970s. The "pharmaceutical revolution" suggested that with medication, patients could become normal, functioning citizens. After a period of training and socialization in halfway houses, patients could be reintroduced into society.
One problem with this is that those halfway houses were closed down because of budget cuts and ... reluctant taxpayers. (For example, the 1970s were also the time of Proposition 13 in California, which dramatically slashed property taxes.) Another problem is that once patients fall off their medication, they lapse back into a dysfunctional state. So instead of being out of their minds in a dungeon, they are now out of their minds at a bus stop or under a bridge -- and vulnerable to nature's elements and to the worst people in society.
One argument is that if mental hospitals were recreated in the 21st century, with medication and counseling, the patients would be relatively normal. The environment in a modern mental hospital would be relatively safe and orderly. The problem with this is that taxpayers prefer to fund things that are tangibly beneficial in their own lives, and to them, the fate of the severely mentally ill is an abstraction. (Even if a program did help to remove many homeless from the streets -- which taxpayers could see with their own eyes -- and taxpayers were initially enthusiastic over this, over time they would forget about it, and pressure would eventually mount to end the program.)
So how to create an environment for patients where they are under supervision so that 1) they can be compelled to take their medication, and 2) they are protected from abuse?
Moreover, how can this be done in a cost-effective manner?
Here's a hybrid proposal -- to create an environment that is both a self-enclosed hospital and also an actual society.
One would take an entire small town and turn it into a functioning "hospital". Patients would live and work in their small town ... permanently. No one would leave, and, with few exceptions, nobody would be allowed to enter from the outside world. It would be a functioning society run largely by the patients, but it would be a very supervised, controlled environment -- in fact, a hospital.
How big would these hopital towns be? Schizophrenics supposedly make up 1% of the population, so roughly 1% of people would live in these hospital communities. Of course, some schizophrenics are already assimilated into society, but this percentage gives a general idea. Also, a "hospital town" could serve more than just patients who suffered from schizophrenia.
In any case, almost anything seems better than the current system, which is to dump helpless folks on the street.
