Deinstutionalization: The Illusion of Policy

Journal of Policy History

Volumn 9, Issue 1, 1997, Pages 48-73

  Grob, Gerald N ^a  

^a RUTGERS UNIVERSITY   (United States)

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EID: 84994740140     PISSN: 08980306     EISSN: 15284190     Source Type: Journal    
DOI: 10.1017/S0898030600005820     Document Type: Article

References (126)

1. See for example the data provided by Edward Jarvis in his Report on Insanity and Idiocy in Massachusetts by the Commission on Lunacy Under Resolve of the Legislature of 1854 (Mass. House Document No. 144 [1855]) (Boston 1855), 18, 73.
2. For discussions of this theme, see Gerald N. Grob, Mental Illness and American Society, 1875–1940 (Princeton, 1983)
3. From Asylum to Community: Mental Health Policy in Modem America (Princeton, 1991)
4. “Government and Mental Health Policy: A Structural Analysis,” Milbank Quarterly 72 (1994): 471–500.
5. Ellen Dwyer, Homes for the Mad: Life Inside Two Nineteenth-Century Asylums (New Brunswick, 1987), 150–151
6. U.S. Bureau of the Census, Insane and Feeble-Minded in Hospitals and Institutions 1904 (Washington, D.C., 1906), 37
7. idem., Insane and Feeble Minded in Institutions 1910 (Washington, D.C., 1915), 59
8. idem., Patients in Hospitals for Mental Disease, 1923 (Washington, D.C., 1926), 36
9. Neil A. Dayton, New Facts on Mental Disorders: Study of 89, 190 Cases (Springfield, Ill., 1940), 414–429.
10. Benjamin Malzberg, “A Statistical Analysis of the Ages of First Admissions to Hospitals for Mental Disease in New York State,” Psychiatric Quarterly 20 (1949): 344–366
11. idem., “A Comparison of First Admissions to the New York Civil State Hospitals During 1919–1921 and 1949–1951,” Psychiatric Quarterly 28 (1954): 312–319
12. New York State Department of Mental Hygiene, Annual Report, 42 (1939–1940): 174–175
13. Herbert Goldhamer and Andrew W. Marshall, Psychosis and Civilization: Two Studies in the Frequency of Mental Disease (Glencoe, Ill., 1953), 54, 91
14. American Psychiatric Association, Report on Patients Over 65 in Public Mental Hospitals (Washington, D.C., 1960), 5.
15. Statistics compiled from U.S. Bureau of the Census, Patients in Hospitals for Mental Disease 1923
16. Mental Patients in State Hospitals 1926 and 1927 (Washington, D.C., 1930)
17. Patients in Mental Hospitals 1940 (Washington, D.C., 1943)
18. Morton Kramer, Psychiatric Services and the Changing Institutional Scene, 1950–1985 (DHEW Publication No. [ADM] 76–374: Washington, D.C.: Government Printing Office, 1977), 75.
19. Grob, From Asylum to Community, passim.
20. The most famous included Albert Q. Maisel, “Bedlam 1946,” Life 20 (May 6, 1946): 103–118
21. Frank L. Wright, Out of Sight Out of Mind (Philadelphia, 1947)
22. Mike Gorman, “Oklahoma Attacks Its Snakepits,” Reader's Digest 53 (September 1948): 139–160
23. Albert Deutsch, The Shame of the States (New York, 1948).
24. Mary Jane Ward's novel The Snake Pit (New York, 1946), was subsequently made into a famous motionpicture in 1948.
25. For a detailed discussion of the expanded role of the federal government, see Grob, From Āsylum to Community.
26. Harold Sampson, David Ross, Bernice Engle, and Florine Livson, “Feasibility of Community Clinic Treatment for State Mental Hospital Patients,” Archives of Neurology and Psychiatry 80 (1958): 77.
27. A larger version of this study appeared under the title A Study of Suitability for Outpatient Clinic Treatment of State Mental Hospital Admissions 1957, California Department of Mental Hygiene Research Report No. 1 (1957).
28. See Morton Kramer, Some Implications of Trends in the Usage of Psychiatric Facilities for Community Mental Health Programs and Related Research (U.S. Public Health Service Publication 1434: Washington, D.C., 1967)
29. idem., “Epidemiology, Biostatistics, and Mental Health Planning,” in American Psychiatric Association Psychiatric Research Reports 22 (1967): 1–68
30. Kramer, C. Taube, and S. Starr, “Patterns of Use of Psychiatric Facilities by the Aged: Current Status, Trends, and Implications,” in American Psychiatric Association Psychiatric Research Reports 23 (1968): 89–150.
31. Donald G. Langsley, “The Community Mental Health Center: Does It Treat Patients?,” Hospital & Community Psychiatry 31 (1980): 815–819
32. Rosalyn D. Bass, CMHC Staffing: Who Minds the Store? (DHEW Publ. [ADM] 78–686: Washington, D.C., 1978)
33. David A. Dowell and James A. Ciarlo, “An Evaluative Overview of the Community Mental Health Centers Program,” in Handbook on Mental Health Policy in the United States, ed. David A. Rochefort (Westport, Conn., 1989), 206.
34. This paragraph is based upon an examination of the following sources: 92–2 Congress, Extend Community Mental Health Centers Act: Hearing before the Subcommittee on Public Health and Environment of the Committee on Interstate and Foreign Commerce House of Representatives… 1972 (Washington, D.C., 1972)
35. 93–1 Congress, Public Health Service Act Extension 1973: Hearing before the Committee on Labor and Welfare United States Senate …1973 (Washington, D.C., 1973)
36. 93–1 Congress, Departments of Labor, and Health, Education and Welfare and Related Agencies Appropriations for Fiscal Year 1974: Hearings before a Subcommittee of the Committee on Appropriations United States Senate (Washington, D.C., 1973)
37. General Accounting Office, “Community Mental Health Centers Program– Improvements Needed in Management,” July 8, 1971 (B-164031[2])
38. “Need for More Effective Management of Community Mental Health Centers Program,” August 27, 1974 (B-16403115]); Public Law 94–63
39. U.S. Statutes at Large, 89:304–369 (July 29, 1975)
40. Public Law 95–83
41. Public Law, 91:383–399 (August 1, 1977)
42. Public Law 95–622
43. Public Law, 92:3412–3442 (November 9, 1978).
44. For analyses of the policy debates of the early 1970s see Henry A. Foley, Community Mental Health Legislation: The Formative Process (Lexington, 1975)
45. Walter E. Barton and Charlotte J. Sanborn, eds., An Assessment of the Community Mental Health Movement (Lexington, 1977)
46. Henry A. Foley and Steven S. Sharfstein, Madness and Government: Who Cares for the Mentally Ill? (Washington, D.C., 1983)
47. E. Fuller Torrey, Nowhere to Go: The Tragic Odyssey of the Homeless Mentally Ill (New York, 1988)
48. Lisa Reichenbach, “The Federal Community Mental Health Centers Program and the Policy of Deinstitutionalization,” mss. prepared for the NIMH under Grant No. MH27738–02 (1980).
49. Report to the President from The President's Commission on Mental Health 1978 (4 vols.: Washington, D.C., 1978)
50. General Accounting Office, Returning the Mentally Disabled to the Community: Government Needs to Do More (Washington, D.C., 1977)
51. Mentoi Health Systems: Message from the President of the United States (May 15, 1979) (Washington, D.C., 1979)
52. 96–1 Congress, Mental Health Systems Act, 1979: Hearings before the Subcommittee on Health and Scientific Research of the Committee on Labor and Human Resources United States Senate … 1979 (Washington, D.C., 1980)
53. 96–1 Congress, Mental Health Systems Act: Hearings before the Subcommittee on Health and the Environment of the Committee on Interstate and Foreign Commerce House of Representatives … 1979 (Washington, D.C., 1979)
54. 96–2 Congress, Community Mental Health Centers, Oversight: Hearing before the Subcommittee on Health and the Environment of the Committee on Interstate and Foreign Commerce House of Representatives … 1980 (Washington, D.C., 1980)
55. Public Law 96–398
56. U.S. Statutes at Large, 94:1564–1613 (October 7, 1980).
57. The best description of the history of the act is Foley and Sharfstein, Madness and Government, 118–134.
58. The literature dealing with mental health law since the 1960s is immense. For overviews see the following: Alexander D. Brooks, Law, Psychiatry and the Mental Health System (Boston, 1974)
59. the 1980 Supplement (Boston, 1980) to this volume
60. David Mechanic, Mental Health and Social Policy (3rd ed.: Englewood Cliffs, New Jersey, 1989), 213–234
61. Paul S. Appelbaum, “The Right to Refuse Treatment with Antipsychotic Medications: Retrospect and Prospect,” American Joumal of Psychiatry 145 (1988): 413–419
62. Gerald L. Klerman, “The Psychiatric Patient's Right to Effective Treatment: Implications of Osheroff v. Chestnut Lodge,” American Joumal of Psychiatry, 147 (1990): 409–418
63. Alan A. Stone, “Law, Science, and Psychiatric Malpractice: A Response to Klerman's Indictment of Psychoanalytic Psychiatry,” American Joumal of Psychiatry, 419–427.
64. See Alan Stone, “Overview: The Right to Treatment–Comments on the Law and Its Impact,” American Journal of Psychiatry 132 (1975): 1125–1134.
65. Group for the Advancement of Psychiatry, Report No. 79 (November 1970): 662
66. Bruce C. Vladeck, Unloving Care: The Nursing Home Tragedy (New York, 1980).
67. General Accounting Office, Returning the Mentally Disabled to the Community, 81
68. Ann B. Johnson, Out of Bedlam: The Truth About Deinstitutionalization (New York, 1990), 94–95
69. Dorothy P. Rice, S. Kelman, L. S. Miller, and S. Dunmeyer, The Economic Costs of Alcohol and Drug Abuse and Mental Illness: 1985 (San Francisco, 1990), 76, 108, 110.
70. Public Law 92–603
71. U.S. Statutes at Large, 86:1329–1492 (October 30, 1972)
72. Johnson, Out of Bedlam, 96–99.
73. See also Edward D. Berkowitz, Disabled Policy: America's Programs for the Handicapped (New York, 1987).
74. The claim that the massive decline in the number of inpatients at state mental hospitals began with the development of the psychotropic drugs in the 1950s in simply not substantiated by the data. See especially William Gronfein, “Incentives and Intentions in Mental Health Policy: A Comparison of the Medicaid and Community Mental Health Programs,” Journal of Health and Social Behavior 26 (1985): 192–206.
75. NIMH, Mental Health United States, 1990, ed. Ronald W Manderscheid and Mary A. Sonnenschein (Washington, D.C., 1990), 31, 158, 160
76. David Mechanic and D. A. Rochefort, “Deinstitutionalization: An Appraisal of Reform,” Annual Review of Sociology 16 (1990); 308–313
77. Joseph P. Morrissey, “The Changing Role of the Public Mental Hospital,” in Handbook on Mental Health Policy, ed. D.A. Rochefort, 311–338
78. Howard Goldman, C. A. Taube, D. A. Regier, and M. Witkin, “The Multiple Functions of the State Mental Hospital,” American Journal of Psychiatry 140 (1983): 296–300.
79. See especially Henry Santiestevan, Deinstitutionalization: Out of Their Beds and into the Streets, a pamphlet published by the American Federation of State, County and Municipal Employees in 1975
80. reprinted in the American Journal of Psychiatry 132 (1975): 95–137.
81. Howard H. Goldman. N. H. Adams, and C. A. Taube, “Deinstitutionalization: The Data Demythologized,” Hospital & Community Psychiatry 34 (1983): 129–134
82. Jon E. Guderman and Miles F. Shore, “Beyond Deinstitutionalization: A New Class of Facilities for the Mentally Ill,” New England Journal of Medicine 311 (1984): 832–835.
83. The persistence of the state hospital, as a matter of fact, is mirrored in a variety of data. Between 1969 and 1983 expenditures for state hospital systems increased in current dollars from $1.8 to $5.5 billion (in constant dollars there was a slight decline from $1.8 to $1.7 billion). In 1986 there were 286 state and county hospitals, eleven more than in 1955 but down from the high of 334 in 1973. See NIMH, Mental Health, United States, 1987. ed. Ronald W. Manderscheid and S. A. Barrett (Washington, D.C., 1987), 56–57
84. Mechanic and Rochefort, “Deinstitutionalization,” 308ff.
85. Courtenay M. Harding, George W. Brooks, Takamaru Ashikaga, John S. Strauss, and Alan Breier, “The Vermont Longitudinal Study of Persons with Severe Mental Illness, I: Methodology, Study Sample, and Overall Status 32 Years Later,”
86. “The Vermont Longitudinal Study of Persons with Severe Mental Illness, II: Long Term Outcome of subjects Who Retrospectively Met DSM-III Criteria for Schizophrenia,” American Journal of Psychiatry 144 (1986): 718–735.
87. Esso Leete, “The Treatment of Schizophrenia: A Patient's Perspective,” Hospital & Community Psychiatry 38 (1987): 486–491
88. Sarah Rosenfield, “Factors Contributing to the Subjective Quality of Life of the Chronic Mentally Ill,” Journal of Health and Social Behavior 33 (1992):299–315.
89. In an as yet unpublished study, Allan Horwitz interviewed 142 individuals on the threshold of release from a mental hospital. Not a single individual expressed a preference for institutionalization; all looked forward to resuming their lives in the community. Allan Horwitz, personal communication, June, 1993.
90. U. S. Bureau of the Census, Historical Statistics of the United States, Colonial Times to 1970 (2 vols.: Washington, D.C. 1975), I, 49
91. Kramer, Psychiatric Services and the Changing Institutional Scene, 1950–1985, 46
92. Leona L. Bachrach, “Young Adult Chronic Patients: An Analytical Review of the Literature,” Hospital & Community Psychiatry 33 (1982): 189–197.
93. Bert Pepper, H. Ryglewicz, and M. C. Kirschner, “The Uninstitutionalized Generation: A New Breed of Psychiatric Patient,” in The Young Adult Chronic Patient, ed. Pepper and Ryglewicz (San Francisco, 1982), 5.
94. See also Bachrach, “The Homeless Mentally Ill and Mental Health Services: An Analytical Review of the Literature,” in The Homeless Mentally 1ll: A Task Force Report of the American Psychiatric Association, ed. H. Richard Lamb (Washington, D.C., 1984), 11–53.
95. Bachrach, “The Concept of Young Adult Chronic Psychiatric Patients: Questions from a Research Perspective,” Hospital & Community Psychiatry 35 (1984): 574
96. Lamb, “Deinstitutionalization and the Homeless Mentally Ill,” in The Homeless Mentally Ill, 65.
97. Pamela J. Fischer and W. R. Breakey, “The Epidemiology of Alcohol, Drug, and Mental Disorders Among Homeless Persons,” American Psychologist 46 (1991): 1115–1128
98. Deborah L. Dennis, J. C. Buckner, F. R. Lipton, and I. S. Levine, “A Decade of Research and Services for Homeless Mentally Ill Persons,” American Psychologist, 1129–1138
99. Dennis McCarty, M. Algeriou, R. B. Huebner, and B. Lubran, “Alcoholism, Drug Abuse, and the Homeless,” American Psychologist, 1139–1148
100. Robert E. Drake, F. C. Osher, and M. A. Wallach, “Homelessness and Dual Diagnosis,” American Psychologist, 1149–1158
101. Ronjemelka, E. Trupin, and J. A. Chiles, “The Mentally Ill in Prisons: A Review,” Hospital & Community Psychiatry 40 (1989): 481–491.
102. See also Hospital & Community Psychiatry, 43 (1992): 1253–1254.
103. See Stuart R, Schwartz and S. M. Goldfinger, “The New Chronic Patient: Clinical Characteristics of an Emerging Subgroup,” Hospital & Community Psychiatry 32 (1981): 473
104. Barriers to Treating the Chronic Mentally Ill, ed. Arthur T Meyerson (San Francisco, 1987).
105. Department of Health and Human Services, Toward a National Plan for the Chronicolly Mentally Ill (Washington, D.C., 1980).
106. Howard H. Goldman and A. A. Gattozzi, “Murder in the Cathedral Revisited: President Reagan and the Mentally Disabled,” Hospital & Community Psychiatry 39 (1988): 505–509
107. “Balance of Powers: Social Security and the Mentally Disabled, 1980–1985,” Milbank Quarterly 66 (1988): 531–551.
108. In the late 1980s and early 1990s both television and the printed media highlighted two cases in New York of homeless mentally ill persons (Joyce Brown [more popularly known as Billy Boggs] and Larry Hogue). Descriptions of these cases can be found in Rael J. Isaac and V. A. Armat, Madness in the Streets: How Psychiatry and the Law Abandoned the Mentally Ill (New York, 1990), 256–60, 346–47
109. Pepper and Ryglewicz, Young Adult Chronic Patient, 121
110. John A. Talbott, “Deinstitutionalization: Avoiding the Disasters of the Past,” Hospital & Community Psychiatry 30 (1979): 623
111. David Mechanic, “Correcting Misconceptions in Mental Health Policy: Strategies for Improved Care of the Seriously Mentally Ill,” Milbank Quarterly 65 (1987): 203–230
112. “Strategies for Integrating Public Mental Health Services,” Hospital & Community Psychiatry 42 (1991): 797–801.
113. Richard C. Tessler and H. H. Goldman, The Chronically Mentally Ill: Assessing Community Support Programs (Cambridge, 1982)
114. Chris Koyanagi and H. H. Goldman, “The Quiet Success of the National Plan for the Chronically Mentally Ill,” Hospital & Community Psychiatry 42 (1991): 901
115. Koyanagi and Goldman, Inching Forward: A Report on Progress Made in Federal Mental Health Policy in the 1980's (Alexandria, Va., 1991), 55–56.
116. Richard C. Tessler, A. G. Bernstein, B. M. Rosen, and H. H. Goldman, “The Chronically Mentally Ill in Community Support Systems,” Hospital & Community Psychiatry 33 (1982): 208–211
117. Koyanagi and Goldman, “The QuietSuccess of the National Plan,” 904.
118. For a review of the Madison model see Kenneth S. Thompson, E. E. H. Griffith, and P. J. Leaf, “A Historical Review of the Madison Model of Community Care,”
119. Mark Olfson, “Assertive Community Treatment: An Evaluation of the Experimental Evidence,” Hospital & Community Psychiatry 41 (1990): 625–641.
120. See also Leonard I. Stein, ed., Innovative Community Mental Health Programs (San Francisco, 1992).
121. See Olfson, “Assertive Community Treatment,” 640.
122. Miles F. Shore and M. D. Cohen, “The Robert Wood Johnson Foundation Program on Chronic Mental Illness: An Overview,” Goldman, A. F. Lehman, J. P. Morrissey, S. J. Newman, R. G. Frank, and D. M. Steinwachs, “Design for the National Evaluation of the Robert Wood Johnson Program on Chronic Mental Illness,”
123. Goldman, Morrissey, and M. S. Ridgely, “Form and Function of Mental Health Authorities at RWJ Foundation Program Sites: Preliminary Observations,” all in Hospital & Community Psychiatry 41 (1990): 1212–1230
124. David Mechanic, “Strategies for Integrating Public Mental Health Services,” 797–801.
125. Koyanagi and Goldman, “The Quiet Success of the National Plan,” 904.
126. The concept of “impure science” has been used by Arthur Silverstein in his Pure Politics and Impure Science: The Swine Flu Affair (Baltimore, 1981).