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Deinstitutionalization is an awkward and often misunderstood term. Simply stated, it refers to a policy intended to reduce a society’s reliance on large residential facilities that congregate people for care and control under sequestered conditions, frequently against their will and often in centralized public accommodations. Under deinstitutionalization, welfare and control aspects of social regulation are carried out on a smaller scale, largely under voluntary circumstances, in close (or closer) proximity to a person’s home—and more often under the auspices of nongovernmental organizations. Although the process of deinstitutionalization has been most often associated with the management of persons with severe mental illness since the mid-1960s, in the United States the process descended from changes in the child welfare and criminal justice systems of many states beginning early in the twentieth century (for example, the shift from orphanages, often called “industrial homes,” to family foster care or the use of probation and parole as an alternative to incarceration). Indeed, during the past few decades, deinstitutionalization has been seen to one degree or another in the management of lawbreakers, people with alcohol and other drug problems, and those with developmental disabilities and severe musculoskeletal impairments—that is, all groups historically subject to institutional concentration.
Institutional Care As Housing Policy
Deinstitutionalization has been a long-evolving reaction to the dominant institutional solution for a variety of problems. Institutional care and control were appealing for a variety of reasons, but none was more important than the institution’s ability to provide an alternative to a conventional home for those people who had no kin, were extremely burdensome to their families (often because of their disruptive behavior), or whose legal and social transgressions were deemed to warrant isolation in the service of social order. Many famous U.S. citizens were “institutionalized” in private or public facilities: As a boy, baseball great Babe Ruth spent several years before World War I in a Baltimore industrial home that was run by the Catholic church, because his parents couldn’t afford to raise him; during the 1960s, saxophone masters Art Pepper and Frank Morgan, both heroin addicts, played in the same jazz band at San Quentin State Prison near San Francisco, and bebop genius (and polypharmacist) Charlie Parker wrote the famous song “Relaxin’ at Camarillo” in reference to his sojourn of several months at a state mental hospital in southern California in 1947. Most institutions were intended to be transitional settings. They were to subject their residents to a disciplined and beneficial regime of living that would prepare them to resume a place in the noninstitutional world. As it happened, however, a large percentage of institutional residents stayed for a long time or returned repeatedly when their lives outside unraveled. Young men and women grew up in orphanages because their families could never manage to support them or had brutalized them; adults with severe mental illness languished for years in mental hospitals for lack of another receptive home; alcoholics, addicts, and criminals returned repeatedly to hospitals and prisons when their “community adjustment” soured. Institutions of all sorts grew well beyond the population size for which they had been designed. Many, most notably mental hospitals and the “poorhouses” or “county farms” that evolved into public old-age homes, became internally differentiated to separate “chronic” from “acute” cases or, in less clinical language, those with some hope of getting out and those who would never leave.
Inevitably, the “hopeful cases” got the most attention, and the others, the “custodial cases,” were left to spin out their lives in sordid conditions of neglect. The term back ward, used to describe those institutional regions inhabited by the hopeless cases, derives from the location of these areas in the rear parts of buildings hidden from public view.
Dismantling The Institutional Solution
The institutional solution for impairment and waywardness often was degrading, ineffective, expensive—and impervious to meaningful reform. To be sure, mental hospitals, prisons (modern Western prisons, at least), and other institutions did not set out to brutalize and incapacitate at huge public and private cost. In the end, however, many of them did just this (and still do), and their scale, complexity, and resistance to outside interference created formidable barriers to generations of those who would change them. Deinstitutionalization was intended not merely to change but also to dismantle.
Regardless of the population concerned, deinstitutionalization originated from considerations of standards of human liberty and dignity and the creation of cost-effective mechanisms of care and control. However, the historical processes of deinstitutionalization have varied considerably depending on the population at issue. The extraordinary growth of the U.S. prison population since the late 1980s, due in large measure to the long-term incarceration of federal drug offenders under strict minimum sentencing provisions, reminds us that deinstitutionalization occurs under specific historical and political circumstances and that it may proceed quickly on one front while being stalled or reversed on another.
Conceptually, though, the dismantling of the institutional solution has some basic component processes. First, institutional residents must be transferred to other sites of care and control; second, routes into institutions must be changed so that those people who leave are not just replaced by new inmates; and third, the regulatory functions of the institution must be reproduced in noninstitutional settings. As a practical matter, these processes should be undertaken in just the opposite order in which they are listed. It makes little sense to depopulate an institution by transferring residents and preventing the admission of new ones if sufficient and appropriate noninstitutional settings are not in place beforehand.
However, policymaking is not always logical or sufficiently forward-looking. Thus, the controversy about deinstitutionalization mainly concerns this last component of the process. Indeed, some analysts distinguish between institutional depopulation and “community care” rather than invoke the term deinstitutionalization to cover both. Such a distinction emphasizes that although community care might have a logical connection to institutional depopulation, its achievement is neither a political nor a technical given. A government can depopulate institutions quite successfully without providing the resources required if alternative settings are to provide adequate care and control for the same populations. (Early critiques of deinstitutionalization in the mental health field stressed that the new “community-based” programs were serving a relatively healthy population that was categorically distinct from its institutional counterpart.) Further, programs may not be able technically to translate all of the institution’s regulatory functions (notably, secure detention) or its substitute livelihoods to other settings. The state mental hospital census in the United States has declined from its zenith of 559,000 in 1955 to less than 75,000 today, but few would argue that community care is without significant problems.
In theory, the widespread development of “supportive” and “substitutive” services facilitates the dismantling of the institutional solution. Supportive services are intended to maintain people in their own homes with restrictions on their activities only as necessary for their safety or the safety of others. In mental health policy and mental health law parlance, this is known as the principle of “housing in the least restrictive environment.” Substitutive services involve the provision of alternative, supervised environments, with limitations consistent with safety but designed to help someone live the most independent life of which he or she is capable. In their most complete expressions, substitutive services comprise alternative homes that may be permanent or transitional.
A number of factors have contributed to the erosion of political support for deinstitutionalization in the United States. The most important of these factors have been the necessary scale and thus the cost of community care in an era when the huge baby boom generation (those people born between 1946 and 1964) has reached maturity; the persisting shortage of low-income housing that could provide sites of supportive services; and the general reduction in social welfare benefits and services, particularly by state and local governments. One result has been what is sometimes called “transinstitutionalization,” or the transfer of institutionalized persons from one large, congregate institution to another of only somewhat lesser scale and restriction. The most frequently cited example of transinstitutionalization is the transfer of elderly state hospital patients to large nursing homes that began during the 1960s and 1970s. However, during the 1980s and 1990s, the reappearance of mammoth homeless shelters not seen since the Great Depression (1929-1941) raised a similar issue.
Homelessness And Deinstitutionalization
The high prevalence of serious mental disorders among homeless shelter residents often is used as evidence that homelessness is a direct outcome of deinstitutionalization, that homelessness results from the dismantling of institutional solutions in the absence of effective community care. During earlier eras, so the reasoning goes, today’s sheltered mentally ill, including many of those people with concurrent substance use disorders, would have been in state hospitals. In fact, although more permissive civil commitment laws and a much greater institutional capacity significantly prevented homelessness in the past, they did not eliminate it. The grasp of the asylum was never sure, and—the gradual accumulation of “chronic” cases notwithstanding—most institutional sojourns were short. The term revolving door, which has been in use for about fifty years to describe the rapid cycling of people in and out of institutions, is the successor metaphor to rounder, a late nineteenth-century term applied to those people who moved frequently in and out of jails, hospitals, and other similar facilities, making what is sometimes called the “institutional circuit.”
Viewed this way, the relationship between homelessness and deinstitutionalization alerts us to the fact that homelessness is a failure of “abeyance mechanisms” more generally. (Abeyance mechanisms are social arrangements that provide niches for surplus people.) As well, it makes clear that homelessness represents failures in interrelated policy domains, especially those of income maintenance and housing policies, from which deinstitutionalization and the problems of community care cannot be separated.
The presence in shelters of substantial numbers of persons with mental illness provides a good illustration of this interrelatedness. The vast majority of persons with mental illness do not become homeless.
However, the intersection of mental illness and abject poverty often results in homelessness. Although landlords sometimes shun prospective tenants because their symptoms are obvious and difficult to cope with, homeless people with mental illness end up in shelters mainly for the same reason as their healthy peers: In the absence of work or a significant work history, no income maintenance program provides a cash benefit large enough to allow them to purchase housing in a seller’s market. This problem has become more acute since the early 1970s and has been worsened by the stagnant inflation-adjusted value of welfare benefits especially and by the destruction or “conversion to higher use” of the single-room occupancy hotels and other forms of cheap group quarters that once housed the denizens of U.S.skid rows. Indeed, due to the availability of cheap flophouses, the members of that population (no strangers to crime, substance use, and psychiatric problems) rarely were homeless as we most commonly use the term today.
The Future Connection
As noted, deinstitutionalization has proceeded unevenly across the various domains of social care and social control, and we have no reason to think that this will change. To the extent that their members are not perceived to be dangerous, groups with a claim on public sympathy—for example, abused and neglected children, the ill or poor elderly, and the mentally ill or physically impaired—almost certainly will continue to be shielded from a policy of systematic (re)institutionalization. With resentment of minimum sentencing laws growing rapidly among federal judges and with community treatment and criminal justice diversion measures gaining favor in many states, a high percentage of nonviolent drug offenders soon may be steered away from institutionalization. At the same time, though, a large population of long-term inmates of the baby boom generation soon will begin to emerge from U.S. prisons without much in the way of “human capital”—the skills and formal and informal knowledge required for economic survival. Under current circumstances, they are likely candidates for shelter residence.
Whether the supportive and substitutive functions of community care can adequately settle the members of this and other groups depends at least as much on the future of economic and housing policy as it does on innovations in therapy and social rehabilitation. The latter are important, particularly in connection with managing persistent and severe mental illness and substance use without the secure detention afforded by institutional regimes—but without income and housing for those affected, deinstitutionalization will contribute to growing shelter populations.
References:
- Bachrach, L. L. (1978). A conceptual approach to deinstitutionalization. Hospital and Community Psychiatry, 29, 573-578.
- Baumohl, J., & Huebner, R. (1991). Alcohol and other drug problems among the homeless. Housing Policy Debate, 2, 837-865.
- Currie, E. (1993). Reckoning: Drugs, the cities, and the American future. New York: Hill and Wang.
- Hopper, K., Jost, J., Hay, T., Welber, S., & Haugland, G. (1997). Homelessness, severe mental illness, and the institutional circuit. Psychiatric Services, 48, 659-665.
- Oakley, D., & Dennis, D. L. (1996). Responding to the needs of homeless people with alcohol, drug, and/or mental disorders. In J. Baumohl (Ed.), Homelessness in America (pp. 179-186). Phoenix, AZ: Oryx Press.
- Rothman, D. J. (1980). Conscience and convenience: The asylum and its alternatives in progressive America. Boston: Little, Brown.
- White, W. L. (1998). Slaying the dragon: The history of addiction treatment and recovery in America.. Bloomington, IL: Chestnut Health Systems.
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