Deinstitutionalization: How Did We Get Where We Are?

A comparison of deinstitutionalization in different Western nations suggests that the process was stimulated by the opportunity for cost savings created by the introduction of disability pensions and, in some countries, by the postwar demand for labor.

Abstract

More than three decades after the onset of deinstitutionalization in the United States, large numbers of the severely mentally ill receive little or no psychiatric treatment. Many are homeless or in jail, others are housed in boarding homes and nursing homes in conditions scarcely better (if at all) than the back wards of the old state hospitals. Why has this happened? A comparison of deinstitutionalization in different Western nations suggests that the process was stimulated by the opportunity for cost savings created by the introduction of disability pensions and, in some countries, by the postwar demand for labor. Where labor was in short supply, genuinely rehabilitative programs were developed. Where cost saving was the principal motivation, community treatment efforts were weak. In the United States, the tendency to reduce mental hospital beds with minimal community planning was exaggerated by the zeal with which state legislatures embraced the opportunity to pass expenses along to the federal government. Contrary to widespread opinion in American psychiatry, the shift to the community does not appear to have been primarily a response to introduction of the antipsychotic drugs.