Deinstitutionalization of Persons with Severe Mental Illness: Context and Consequences

Journal of Rehabilitation,  April-June, 2001  by Michael P. Accordino,  Dion F. Porter,  Torrey Morse

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In analyzing deinstitutionalization, it is important to consider the historical context of its genesis. Other critical factors include how the community views deinstitutionalization and what rehabilitation professionals need to know to aid its successful implementation. More importantly, rehabilitation professionals need to explore ways to improve deinstitutionalization through improved practice and research. These issues are discussed in the following sections.

Historical Overview

Treatment for people with severe mental illness (SMI) has changed dramatically over the past century. Following the Great Depression of the 1930's and World War II, conditions of state mental hospitals had deteriorated significantly. World War II had a major impact on deinstitutionalization; however, its effects are often understated (Bachrach & Clark, 1996). During the war period, the Barden-Lafollette Act (1943) opened the door for vocational services by mandating that people with SMI receive federal and state rehabilitation/vocational rehabilitation services to people with SMI (Rubin & Roessler, 1995). Furthermore, many servicemen and women developed psychiatric problems during the war. In response, the United States military experimented with different treatment methods that would address these problems and strengthen the war effort. For example, military psychiatrists made major advances in treatment by experimenting with group insight therapy, sedation, and hypnosis (Rochefort, 1984).

Many psychiatrists left employment in state mental hospitals to provide therapeutic treatment as part of private and community practices. By 1955, nearly 80% of the American Psychiatric Association's 10,000 members were employed in outpatient community settings (Grob, 1992). In terms of national policy, the need for community treatment for people with SMI culminated with the National Mental Health Act of 1946. This legislation allowed the federal government to provide grants to states to support existing outpatient treatment centers or build new programs where none existed. In 1948, the Vocational Rehabilitation Act was passed and allowed further vocational rehabilitation services to people with SMI (Arns, 1992).

Prior to 1948, nearly half of the United States had no outpatient clinics; one year later, nearly every state except five had at least one clinic. By 1954, there were approximately 1,234 community outpatient clinics in the country (Grob, 1992). States began to offer increasing support for outpatient clinics in the 1950's. In 1954, New York introduced the Community Mental Health Services Act that mandated financial support for clinics. California enacted similar legislation soon after with the Short-Doyle Act (Grob, 1992). As of 1959, there were over 1,400 outpatient clinics in the country that served approximately 502,000 people with SMI (Grob, 1992).

The 1950's also marked the advent of psychiatric medications. In 1954, the first psychiatric drug, chlorpromazine was marketed (Wegner, 1990). In 1956, two antidepressants, imipramine and iproniazid, were developed (Grob, 1991), and psychopharmacological treatment for people with SMI further reduced the number of people residing in state mental hospitals (Vondracek & Corneal, 1995).

In 1955, the federal government passed the Mental Health Study Act, an Act that authorized a thorough study of the existing mental health system (Rochefort, 1984). The National Institute of Mental Health (NIMH) and the Joint Commission on Mental Illness and Health (JCMIH) conducted numerous studies during this time. After six years of research, the JCMIH summarized a national strategy for treating people with SMI that included: (a) new research on the etiology and treatment methods of SMI, (b) improved training of professionals working in mental health and disability rehabilitation, and (c) organization of enhanced treatment services for people with SMI (Ray & Finley, 1994). Consequently, the JCMIH and NIMH recommended an increase in federal spending for community mental health services, professionals, and facilities.

During the 1960's, deinstitutionalization was reinforced by the emerging social concern of civil rights of people with SMI and a belief that SMI could be prevented as well as treated (Ray & Finley, 1994; Wegner, 1990). In 1963, the Community Mental Health Centers (CMHC) Act was passed and policymakers viewed this legislation as driving deinstitutionalization by shifting treatment for people with SMI from state mental hospitals to "least restrictive environments" within the communities (Bachrach & Clark, 1996; Broskowski & Eaddy, 1994; Levine & Perkins, 1997). The rationale for this legislation was that people treated in proximity to and with the social support of their relatives and friends would require less lengthy and costly treatment (Rochefort, 1984; Torrey, 1997). The objectives of the CMHC Act were for CMHCs to provide services through (a) inpatient treatment, (b) outpatient treatment, (c) partial hospitalization programs, (d) emergency/crisis treatment, and (e) consultation/education (Hadley, Culhane, Mazade, & Manderscheid, 1994).