Deinstitutionalization and the Homeless

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It is nearly impossible to walk between any two points in New Haven without being affected in some small way by our city’s homeless problem. On seeing these people, in many cases, it becomes clear that they suffer from some mental disability that, unaided, will obviously impede their living a normal life. In fact, according to the Report of the Federal Task Force on Homelessness and Severe Mental Illness, one in every three homeless people suffers from a severe mental illness, most of which are treatable. In a country that devotes so many resources to various welfare programs for nearly every group, how can this problem persist? The answer to this question lies in a major national policy shift, deinstitutionalization, which occurred progressively between 1960 and 1980. Though deinstitutionalization addressed a necessary problem, in practice, it only worsens the problems facing the mentally disabled and society at large. What prevailing social ideas and changes brought an end to our nation’s established system of state psychiatric hospitals? What is the logic behind our new and inefficient system of community centered outpatient mental health?
Until the middle of the last century, public mental health in the United States had been the responsibility, for the most part, of individual states, who chose to deal with their most profoundly mentally-ill by housing them safely and with almost total asylum in large state mental hospitals. Free of the stresses we all face in our lives, the mentally-ill faced much better prospects for peaceful lives and even recovery than they would in their conditions in ordinary society. In the hospitals, doctors were always accessible for help, patients were assured food and care, and they could be monitored to insure they never became a danger to themselves or others. Our nation’s state hospital system was a stable, efficient way to help improve the lives of our mentally disabled.
     Around the middle of the last century though, huge developments were made in treating many mental illnesses, which until then had largely been life-long problems. This change made many organizational hospital practices used to insure order and asylum to patients no longer fully necessary. These practices seemed inhumane and excessive on the promise that emerging science could provide alternative treatments to indefinite hospitalization. One huge development that helped turn public opinion against institutionalization of the mentally ill was the introduction of the prefrontal leukotomy. Widely attributed to Portuguese psychiatrist and statesman Dr.

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"Deinstitutionalization and the Homeless." 21 Apr 2018
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Antonio Egaz Moniz, the operation was actually the product of years of research, many of the most influential studies having happened here at Yale under Dr. Carlyle Johnson. An American psychiatrist, Dr. Walter Freedman, was so impressed with the operation’s early results that he developed a faster, less precise form of the surgery which he publicly advertised as a new miracle treatment in psychiatry, and greatly increased its use. Instead of Dr. Moniz’s two small holes drilled on either side of the forehead through which fine tools were used to sever the prefrontal lobe’s syntaxes to the rest of the brain, Freedman pounded an ice pick through the eye cavity and swished the frontal lobe around with the same too until it was completely functionless. These quick and dirty “assembly line lobotomies” provided the perfect fodder for journalists already questioning what they saw as prison-like hospitals that stigmatized the mentally ill while depriving their lives of meaning.
     The response to this sudden outcry against state mental hospitals was the formation of the Joint Commission on Mental Illness and Health which in 1961 published Action for Mental Health, which further decried the efficient state mental hospitals as inhumane, cold places where recovery was impossible. Throughout the next two decades, a string of government actions on both federal and state levels gradually transitioned the national system for the treatment of the mentally ill from state hospitals to community outpatient centers, attempting to mainstream the mentally ill into society, the process now commonly referred to as deinstitutionalization. Rather than re-examine the state hospital system, the nation frantically overturned the stable existing system for a yet unproven network of community care centers which, it was hoped, could handle more effectively and humanely those previously served by the state hospitals, as normal members of society, not stigmatized inmates of institutional asylums.
     Ultimately, however, the process of deinstitutionalization seems to have failed. We have since learned that mainstream reintroduction of the severely mentally ill into society, a solution we hastily deemed acceptable, is really no solution at all. Though we initially decried the state mental hospitals as being inhumane, we are now seeing that asking the mentally ill to fend for themselves in mainstream society while taking their treatment into their own hands is far worse to everybody.
     Asylum as a word has grim connotations today, owing to the prison-like mental hospitals referred to as such. The hospitals were commonly referred to as “asylums” or “insane asylums.” Simply put, however, asylum is merely what the hospitals offered to patients, asylum from the struggles of normal life. The challenges we face on a daily basis in attempting to lead productive lives are nearly overwhelming even when we are healthy. Deinstitutionalization has shown that asking people to deal with all of these stresses on top of their existing condition can be an obviously overwhelming experience. Often, this leads to depression coupled with the existing condition, and the individual is still not able to fully assimilate into society. According to the Federal Task Force on Homelessness and Severe Mental Illness, persons with pre-existing mental illnesses are far more likely to develop depression in difficult situations than persons without. Also, the condition and stresses of homelessness tends to worsen the effects of most severe mental illnesses. Those with pre-existing conditions are far more likely to develop depression and give their condition greater control of their life when faced with the challenges of everyday life than they ever were in the hospital setting, where they held asylum.
     One reason frequently cited for abandoning the state hospital system has been the stigma of mental illness placed on patients in these hospitals. Common sense leads us to ask is the stigma of being in a hospital surrounded by others facing similar challenges is really any worse than the stigma of being homeless and severely mentally ill. It is, in fact, the crippling stigma of the latter that leads many of the homeless mentally ill to avoid human contact and interaction. This common desire to hide costs many the treatment and outreach to which they are entitled under the umbrella of government welfare. Outside the institutional setting, most mentally-ill persons experience little but failure. Severe mental disorders greatly diminish a person’s chances of productive employment or beneficial relationships. Many mentally disabled persons do not easily come to terms with their diminished ability to lead a normal life, and as such interpret every shortcoming as a disappointment. Additionally, the fear and unease we unjustly feel toward the mentally-disabled society at large each time we read about crimes committed by overwhelmed, largely unknowing mentally disabled persons, the small majority who pose any remote threat to themselves or society, is a sweeping emotional cost of the transition with which the mentally disabled population is now burdened.
     Another major point in public opinion against the hospitals was the idea that the care they sometimes had to involuntarily give patients was inhumane. Mainstream media at the time conveyed involuntary treatment as a nightmare of restraints, electroshock, solitary confinement, and generally torturous practices performed on frightened patients, obvious sensationalism in most cases. Associating involuntary treatment only with the large state mental hospitals, however, is a fallacy. In reality, involuntary treatment, at least initially, is the only way many mentally disabled persons will ever follow any structured treatment regimen. By the very nature of most mental illness, and the shame and stigma the mentally disabled feel in normal society, their seeking out the help they need is seldom the case. Were we to look at the issue not as “our moral obligation to protect the wellbeing of the mentally ill by granting them every freedom,” but instead “our moral obligation to protect their well being by seeing that they receive all the care we are capable of offering them to improve their lives,” as the psychiatric community, according to the American Psychiatric Association, always has. In reality, though possibly unpleasant sounding, involuntary treatment is often the only option, whether provided in an institutionalized setting, or a satellite community health center.
     The process of deinstitutionalization, while still fairly young, seems early on to be failing. Statistically, the vast majority of the nation’s mentally ill population is not better off in the least. Though we can easily say that the resources for our mentally disabled population are out there, for countless reasons, access to them is nearly impossible for many people. Because of the difficulty in acquiring statistics on our nation’s homeless population, we cannot say for certain that reversing deinstitutionalization would be a significant fix for our nation’s homeless problem. We can say, however that the conditions the majority of severely mentally disabled persons are placed in now and what they are expected to do in fending for themselves leaves them far worse off than they had been before the process of deinstitutionalization. Though we can easily say that the resources for our mentally disabled population are out there, for countless reasons, access to them is nearly impossible for many people.

Lamb, H. Richard, Leona Bachrach, Frederic Kass, Treating the Homeless Mentally Ill: A Task Force Report of the American Psychiatric Association. Washington, American Psychiatric Association Press. 1993
Renato Sabbatini, "The History of Psychosurgery" (Brain and Mind, June 1997).

Task Force on Homelessness and Sever Mental Illness, Outcasts on Mainstreet, Report of the Task Force on Homelessness and Sever Mental Illness. Washington, US Department of Health and Human Services. 1992.

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