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Ana-Katarina Stanic
Professor Henkel
AMH 2020
2 April 2015
Deinstitutionalization And Its Consequences
In the beginning of the nineteenth century, a strong conviction in the benefits of
institutional care for persons with severe mental illnesses had led to the production of a vast
system of state mental hospitals. In 1955, there was an average daily census of 559,000 patients
in these institutions. By the mid 1960s, the paradigm had shifted dramatically. People began to
lose faith and question the legitimacy of mental health institutions, believing outpatient care to
be a better alternative (Grob 425). The expectation was that these patients, now released into the
general public, would assimilate easily into everyday life. It was quickly seen that this would not
be the case. During the 1960s, the deinstitutionalization of patients in psychiatric facilities
occurred on a mass scale; because of this the number of homeless people rose as the mentally ill
were not able to function independently and successfully.
To understand how dramatically the dynamic shifted, one first has to address what
psychiatric care was in America prior to deinstitutionalization. In 1841, Dorothea Dix, a Boston
schoolteacher, visited the East Cambridge jail where she saw the horrible conditions the mentally
ill were living in. She lobbied until her death in 1887 for policies that were fair and did not treat
mentally ill people as second-rate citizens. Her efforts led to the establishment of 110 psychiatric
hospitals by 1880 (Pan). In 1907, Indiana was one of the first of more than thirty states to enact a

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compulsory sterilization law. This law allowed states to prevent procreation of confirmed
criminals, idiots, imbeciles, and rapists (Indiana Historical Bureau).
Psychiatric care did not seem to be taken seriously in America until it started to affect
nearly every family. How did it affect nearly every family? Because of WWI and WWII. Many
of the soldiers were coming home from the war with wounds that no one could see, and that time
alone would not heal. In 1946 Harry Truman signed the National Mental Health Act, which
called for the establishment of the National Institute of Mental Health (Pan). Finally, research
into neuropsychiatric problems was progressing and real professional advances began to be
made.
In 1954, the first anti-psychotic drug proven to legitimately help with mental illness,
especially schizophrenia and hallucinations/delusions, was approved by the FDA (Frazier 467).
The mid 1950s is when the number of mentally ill patients in psychiatric facilities peaked.
Around this same time is when the critics started the backlash. In 1962, One Flew Over the
Cuckoos Nest, a novel by Ken Kesey, was published (Pan). It is based on his real life
experiences working as a nurses aide in a Veterans Hospital. He does not believe that any of the
patients are mentally ill, but that they merely see the world through a different lens than the rest
of us do. This led the public to further support deinstitutionalization. The beginnings of the
counterculture movement can be felt here as tensions rise between the now more liberal society
and the government that felt they were doing the right thing. President Kennedy felt pressure
from all sides to change something about the policy. This, along with the many advances made in
prescription pills for mental illnesses, is what ultimately led President John F. Kennedy to sign
the Community Mental Health Act in 1963 (Mechanic 302).

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The Community Mental Health Act was a monumental policy. Rarely, in social
policymaking, do measured accomplishments occur faster than stated goals. In the policy
Kennedy called for many changes, which included a reduction by fifty percent or more of the
number of patients then under custodial care within ten or twenty years. In other words, he
wanted at least fifty percent less patients in psychiatric hospitals than there currently were. In
reality, the process of deinstitutionalization occurred much faster. By 1975, the number of
patients in state and county mental hospitals had declined by sixty-two percent from the time of
the Presidents message. By 1985, despite growth in US population and increase in the number
of short hospital stays in mental institutions, the number of patients living permanently in a
mental institution was around 110,000 (Mechanic 302). Compare this to just thirty years earlier
at its peak of 559,000. Where did all of these patients go? It was said that outpatient centers
would be established in the community which would be available for professional consultation,
prescription medicine, and even just support from the community. What was ignored during this
policymaking was that many of those who were in mental institutions were divorced, widowed,
single, or had no families (Frazier 462).
Most of these people were not voluntarily patients - they were too sick and unstable to go
seek the help themselves. Two more acts, passed in 1965 and 1967, respectively, made it even
more difficult than before for the mentally ill to receive proper care (Frazier 468). The first act
was Medicaid. With the passage of Medicaid, states were motivated to move patients out of state
mental hospitals and into nursing homes and general hospitals because coverage did not include
those in institutions for mental diseases. So it is not that the institutions were not there, it is just
that states would have rather docked the cost at a federal level than had to pay for it themselves.

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Eventually, as time progressed, the beds available in psychiatric facilities also decreased
dramatically to reflect that less patients were expected.
The second act was passed in California and set the precedent for mental health
procedures in the rest of the United States. Even to this day, it holds true in most states. This act
was the Lanternman-Petris-Short Act. It made it extremely harder for involuntary
hospitalizations of the mentally ill to occur (California Welfare and Institutions Code). It put the
decision in the hands of someone who was inadequately equipped to make it. The individual who
was mentally ill was completely in charge of their own hospitalization. So, if someone with a
mental illness came into a hospital and chose not to stay they were allowed to leave freely. One
year after the passage of this act, the number of mentally ill people in the criminal justice system
doubles (Pan). One can assume there was a correlation between the mentally ill who now had
more say in their health care and the number of mentally ill in the criminal justice system. When
someone is sick they may have a problem recognizing their illness. This puts them in dangerous
situations that can hinder their welfare and ultimately send them to jail or prison.
What is interesting about this is that Florida took a much different route than other states.
In 1971, the state legislature enacted the Florida Mental Health Act more commonly referred to
as the Baker Act. This put the power in the hands of judges, law enforcement officials,
physicians, or mental health professionals. It gives these individuals the ability to involuntarily
detain and evaluate someone for up to 72 hours if it is believed this person has a possible mental
illness, is a harm to themselves, others, or is acting in a self neglectful nature (Florida Mental
Health Act). Many states now have similar laws but few are as concise and stringent as Floridas.

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The consequences of these policy changes were seen immediately. Of those who were
deinstitutionalized, between fifty and sixty percent had been diagnosed with schizophrenia.
Another ten to fifteen percent were diagnosed with manic-depressive illness or severe
depression. An additional ten to fifteen percent were diagnosed with organic brain diseases epilepsy, strokes, Alzheimers disease, and brain damage secondary to trauma. The remaining
individuals had conditions such as mental retardation with psychosis, autism and other
psychiatric disorders of childhood, and alcoholism and drug addiction with concurrent brain
damage. The fact that most people who were deinstitutionalized suffered from some form of
brain dysfunction was not understood at the time of policymaking (Fuller Torrey). For some
people, the goal of living with a mental illness in the least restrictive setting and with the most
possible dignity was achieved. For most, it meant having the self-determination to choose
between soup kitchens. The least restrictive setting turned into a cardboard box, a jail cell, or a
terror-filled existence plagued by both real and imaginary enemies.
According to Shervert H. Frazier in Responding to the Needs of the Homeless Mentally
Ill, 3 categories of homeless people exist: those who have suffered recent economic turmoil,
those who have experienced personal crises, and those who are severely disabled by mental
illness or substance abuse disorders. Many of those who are homeless and mentally ill have been
stigmatized (Frazier 464). Because they had been stigmatized these mentally ill people had
nowhere to go but homeless shelters. It was estimated that fifteen percent of the individuals in
New York City homeless shelters had some form of severe mental illness (Frazier 464). These
individuals lived their lives with zero dignity. Surviving on hand outs caused these individuals to

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fall even deeper into a hole they could not climb out of it, and drugs became a rampant problem
within the homeless mentally ill community (Frazier 467).
Deinstitutionalization had let down the individuals it was meant to serve. Most were on
the streets homeless, unable and unsure of how to begin their new free lives. A vicious cycle of
picking up the homeless, sending them to jail, sending them to a community health center, and
immediately putting them back onto the street again began (Grob 428).
One can look at incarcerated individuals like George Wooten as a testimony to what
deinstitutionalization accomplished. By May 1984, 32 year old Wooten had been jailed over 100
times. This included 28 times in the previous 2 years solely for creating disturbances in the
community. Wooten had been diagnosed with schizophrenia at age 17, and each time he used
alcohol or sniffed glue or paint, it exacerbated his schizophrenia and led to the behavior that put
him into jail at least 28 times (Fuller Torrey). Wooten was 17 in 1969. This was a long 6 years
after President John F. Kennedys initial decision to enact the Community Health Act. George
Wootens life is a prime example of how deinstitutionalization affects not only those who are ill
at the time, but indefinitely changes the future for those who become ill after the policy. The
hospital beds have been eliminated and receiving adequate care was never a choice George
Wooten even had.
It seems as if the situation for the mentally ill was and is hopeless. Nothing improved.
When President Jimmy Carter assumed office in early 1977, he created a presidential
commission on mental health. The creation of this commission was symbolic, it showed that the
president knew there was an issue and was expressing concern (Grob 425). This was the first
presidential commission ever created to tackle mental health policy. Although President Carter

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showed an interest in changing the way mental health was dealt with, he still did not understand
how to properly tackle the problem. He believed that unemployment and discrimination were
large playing factors in the lives of the mentally ill but they were not. His commission consisted
of twelve men and eight women, three African Americans, two Hispanics, and one Native
American. Although they created many plans and addressed many real issues, little real change
occurred (Grob 431). In 1979, President Carter signed the Mental Health Systems Act. The
ultimate goal was to improve the amenities available to those are chronically mentally ill.
President Carter still believed that the mentally ill should live in the least restrictive setting
possible. As stated in his message to Congress: There are approximately 1.5 million chronically
mentally disabled adults in mental hospitals, nursing homes and other residential facilities. Many
of these individuals could lead better lives in less restrictive settings if mental health and
supporting services were available in their communities (Grob 438). The only real change that
occurred from this act was that research began to be done into the lives of the chronically
mentally ill. What the research found was what many already knew - almost 30 percent of all
homeless people had some kind of mental illness (Frazier 467).
When President Reagan takes office in 1981, yet again, the mental health community
receives no support. He enacts the Omnibus Budget Reconciliation Act (Pan). This repeals
Carters act and establishes block federal grants for states. Federal mental health spending
decreases by 30 percent (Grob 468). It began to be too hard to truly grasp the extent of the
mental health problems within the homeless community because no one was keeping track of
those who had been deinstitutionalized. Many were homeless and sick. The pieces just never
seemed to come together for these individuals. There was also the issue of the young adult

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chronic patients. They grew up in an America that had no system of care (Frazier 464). They
believed being homeless was an undeniable fate, and they were sick and frequently becoming
drug addicts.
The situation for the mentally ill, especially those trapped in the cycle of homelessness, is
similar even to today in America. It was estimated that in 2004, there were about three times as
many more seriously mentally ill people in jails and prisons than in hospitals. In 2009, during the
great recession, the largest cut in funding seen since the beginnings of deinstitutionalization
occurred (Pan). This leaves one to wonder just how different the fate of our countrys sick and
poor would have been without deinstitutionalization. Because of the deinstitutionalization that
occurred during the 1960s, and the laws that followed, many patients from psychiatric facilities
ended up homeless as they were not able to function independently and successfully. Because of
the lack of adequate follow-up care and facilities, many more mentally ill individuals would and
do suffer.

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Works Cited
"California Welfare and Institutions Code." California Welfare and Institutions Code.
Web. 18 Mar. 2015. <http://www.leginfo.ca.gov/cgi-bin/calawquery?
codesection=wic>.
"Florida Mental Health Act." Statutes & Constitution. Web. 18 Mar. 2015.
<http://www.leg.state.fl.us/Statutes/index.cfm?
App_mode=Display_Statute&URL=0300-0399%2F0394%2F0394.html>.
Frazier, Shervert H. "Responding to the Needs of the Homeless Mentally Ill." Association
of Schools of Public Health 100.5 (1985): 462-69. JSTOR. Web. 12 Mar. 2015.
Fuller Torrey, E., M.D. "Chapter 1 and 3." Out of the Shadows: Confronting America's
Mental Illness Crisis. New York: John Wiley & Sons, 1997. Print.
Grob, Gerald N. "Public Policy and Mental Illnesses: Jimmy Carter's Presidential
Commission on Mental Health." The Milbank Quarterly 83.3 (2005): 425-56.
JSTOR. Web. 12 Mar. 2015.
"Indiana Historical Bureau." IHB: 1907 Indiana Eugenics Law. Web. 17 Mar.
2015. <http://www.in.gov/history/markers/524.htm>.
Mechanic, David, and David A. Rochefort. "Deinstitutionalization: An Appraisal of
Reform." Annual Reviews 16 (1990): 301-27. JSTOR. Web. 12 Mar. 2015.
Pan, Deanna. "TIMELINE: Deinstitutionalization and Its Consequences." Mother Jones.
Mother Jones, 29 Apr. 2013. Web. 14 Mar. 2015.