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Section 1: Looking Ahead and Reflecting Upon the Past

Chapter 2. Mental Health Policy in 20th-Century America

Gerald N. Grob, Ph.D. Rutgers, The State University of New Jersey

In mid-19th-century America, the asylum was widely regarded as the symbol of an enlightened and progressive nation that no longer ignored or mistreated its insane citizens. The justification for asylums appeared self-evident: they benefited the community, the family, and the individual by offering effective medical treatment for acute cases and humane custodial care for chronic cases. In providing for persons with mental illness, the State met its ethical and moral responsibilities and, at the same time, contributed to the general welfare. After World War II, by way of contrast, the mental hospital began to be perceived as the vestigial remnant of a bygone age. Increasingly, the emphasis was on prevention and the provision of care and treatment in the community. Indeed, during the 1960's, many mental health professionals were fond of referring to a new psychiatric revolution equal in significance to the first revolution begun by Philippe Pinel, who allegedly removed the chains of Parisian "lunatics" in 1793. The new policy, in short, assumed the virtual abolition of traditional mental hospitals and the creation in their place of community alternatives.

What elements shaped the transition from an institutional-to a community-based policy? The answer to this question is more complex than is commonly recognized, for the foundations of change had their origins in the late 19th century. Public policies, after all, are more often than not evolutionary in nature; only rarely do they emerge in some novel form following a cataclysmic event. Mental health policies were no exception; the changes that occurred after 1945 were linked with earlier developments.

Origins of Change

Of major significance in preparing the foundations for new community-oriented policies was the change in the nature of the patient population of mental hospitals after 1890. Between the 1830's and 1880's, the proportion of persons with long-term care in hospitals was relatively low as compared with the extraordinary high percentage between 1890 and 1950. Funding patterns played a key role in inhibiting the increase in this caseload. In general, State legislatures provided the capital funds necessary for acquiring new sites and constructing, expanding, and renovating existing physical plants. Local communities, on the other hand, were required to pay hospitals a sum equal to the actual cost of care and treatment of each patient admitted. The system, moreover, did not assume that every person with mental illness would be cared for in a State institution. Laws generally required that only persons with mental illness who were dangerous had to be sent to State hospitals. Others who presumably could benefit from therapeutic interventions (and, thus, ultimately be removed from welfare rolls) could, at the discretion of local officials, also be institutionalized. The system, in short, involved divided responsibility. For much of the 19th century, therefore, a significant proportion of persons with mental illnesses either continued to live in the community or else were kept in municipal almshouses. Families with sufficient resources could commit their relatives to State institutions, provided they were willing to assume financial liability for their upkeep. States, moreover, had to reimburse hospitals for those patients who had not established legal residency, such as immigrants. The result was a variegated pattern (Grob, 1994b).

Divided responsibility for persons with mental illness had significant repercussions. The system tended to promote competition and rivalries between overlapping governmental jurisdictions. In many States, the stipulation that individual communities were financially liable for their poor and indigent "insane" residents created incentives for local officials to keep them in almshouses where costs were lower. Hospital officials often faced unremitting pressure from communities to discharge patients— irrespective of their condition— in order to save money. Local officials occasionally even attempted to force hospitals to reimburse the community for work performed by patients, though such labor was frequently considered to be part of a therapeutic regimen. Ironically, divided fiscal and government authority had the paradoxical effect of keeping persons with long-term care needs in mental hospitals at relatively low levels (Grob, 1973, 1983).

As the number of persons with long-term care increased, however, States slowly began to reconsider their policies. Disillusioned by a system that divided authority, States— led by New York and Massachusetts— adopted legislation that relieved local communities of any role whatsoever in caring for people with mental illness. The assumption of those who favored centralization was that local care, although less expensive, was substandard and fostered chronicity and dependency. Conversely, care and treatment in hospitals, though more costly initially, would be cheaper in the long run because it would enhance the odds of recovery for some and provide more humane care for others (Grob, 1983).

Although the intent of State assumption of responsibility was to ensure that persons with mental illnesses would receive a higher quality of care and treatment, the consequences in actual practice turned out to be quite different. In brief, local officials saw in the new laws a golden opportunity to shift some of their financial obligations onto the State. The purpose of the legislation was self-evident, namely, to remove the care of people with long-term mental illness from local jurisdictions. But local officials went beyond the intent of the law. Traditionally, 19th-century almshouses (which were supported and administered by local governments) served in part as old-age homes for senile and aged persons without any financial resources. The passage of State care acts provided local officials with an unexpected opportunity. They proceeded to redefine senility in psychiatric terms and thus began to transfer aged persons from local almshouses to State mental hospitals. Humanitarian concerns played a relatively minor role in this development; economic considerations were of paramount significance (Grob, 1983).

Faced with an opportunity to shrink expenditures, communities were more than happy to transfer responsibility for their aged residents to State-supported facilities. Between 1880 and 1920, therefore, the almshouse populations (for this and other reasons) dropped precipitously. Admissions fell from 99.5 to 58. 4 per 100,000 between 1904 and 1922. The decline in the number of persons with mental illness aged 60 and over was even sharper, dropping from 24.3 percent in 1880 to 5. 6 percent in 1923 (U.S. Bureau of the Census, 1906a, 1906b, 1915, 1925, 1926). What occurred, however, was not a deinstitutionalization movement, but rather a lateral transfer of individuals from one institution to another.

During the first half of the 20th century, as a result, the character of mental hospitals underwent a dramatic transformation. By 1904, only 27.8 percent of the total patient population had been institutionalized for 12 months or less. Six years later this percentage fell to 12.7, although it rose to 17.4 in 1923. The greatest change, however, came among patients hospitalized for 5 years or more. In 1904 39.2 percent of patients fell into this category; in 1910 and 1923 the respective percentages were 52.0 and 54. 0 (U.S. Bureau of the Census, 1906b, 1914, 1925). Although data for the United States as a whole were unavailable after 1923, the experiences of Massachusetts are illustrative: by the 1930's, nearly 80 percent of its mental hospital beds were occupied by persons with long-term care needs (Dayton, 1940).

Chronicity, however, is a somewhat misleading term for persons with long-term care needs, for the group that it described was actually heterogeneous. The aged (over 60 or 65) constituted by far the single largest component. By 1920, for example, 18 percent of all first admissions to New York State mental hospitals were diagnosed with psychoses because of senility or arteriosclerosis; 20 years later the figure had risen to 31 percent. A decade later 40 percent of all first admissions were aged 60 and over, as compared with only 13.2 percent of the State's total population (Malzberg, 1949, 1954; New York State Department of Mental Hygiene, 1939–1940). The increase in the absolute number also reflected a change in age-specific admission rates. In their classic study of rates of institutionalization covering more than a century, Goldhamer and Marshall found that the greatest increase occurred in the older category. In 1855, the age-specific first-admission rate in Massachusetts aged 60 and over was 70.4 for males and 65. 5 for females (per 100,000); by the beginning of World War II, the corresponding figures were 279.5 and 223.0 (Goldhamer & Marshall, 1953). As late as 1958, nearly a third of all resident State hospital patients were over age 65 (American Psychiatric Association, 1960).

The rising age distribution mirrored a different but related characteristic of people in institutions, namely, the presence of large numbers of patients whose abnormal behavior reflected an underlying somatic etiology. Even allowing for imprecise diagnoses and an imperfect statistical reporting system, it was quite evident that a significant proportion of the hospitalized population suffered from severe organic disorders for which there were no effective treatments. Of 49,116 first admissions in 1922 admitted because of various psychoses, 16,407 suffered from a variety of identifiable somatic conditions (senility, cerebral arteriosclerosis, paresis, Huntington's chorea, brain tumors, etc.). Between 1922 and 1940, the proportion of such patients increased from 33.4 to 42.4 percent. In 1946 various forms of senility and paresis accounted for about half of all first admissions (Kramer, 1976; U.S. Bureau of the Census, 1925, 1930, 1943).

The change in the character of mental hospitals also altered their links with psychiatry. Trained as physicians, psychiatrists clearly preferred a therapeutic rather than a custodial role. Yet, the institutional context in which they practiced in the early 20^th century was hardly conducive to the pursuit of the former. Moreover, the rise of modern "scientific" medicine appeared to accentuate still further the seemingly obsolescent character of psychiatry. Under such circumstances, it was understandable that psychiatrists between 1890 and World War II began to redefine the concepts of mental disorders and therapeutic interventions, as well as the very context in which they practiced. In so doing, they began to distance themselves from traditional mental hospitals, which— unlike their 19th-century predecessors— had large numbers of long-term and especially aged patients whose need for general care was paramount.

The Attack on Mental Hospitals and Creation of New Community Policies

By the mid-1940's it had become clear that the character of mental hospitals had been transformed by the nature of their patient populations. The presence of so many aged persons and other patients suffering from such diseases as irreversible somatic disorders signified that institutions were providing custodial care for those who would remain until they died. In the immediate postwar years, journalists and mental health professionals alike published numerous critical accounts of mental hospitals even though their analyses were not always accurate. Admittedly, a decade-and-a-half of financial neglect, due largely to the combined impact of the Great Depression of the 1930's and global conflict of the 1940's, simply exacerbated already existing severe problems. It is frequently supposed that the depressing state of mental hospitals was as much a function of the nature of their patients as it was the result of parsimonious or callous policies. The large number of persons with long-term care needs was considered the single most significant element in shaping a milieu seemingly antithetical to therapeutic goals.

Mental hospitals— institutions that had been the cornerstone of public policy for nearly a century and a half— slowly began to lose their social and medical legitimacy. This was hardly surprising. Indeed, after World War II the prevailing consensus on mental health policy slowly began to dissolve. Developments converged to reshape public policy during these years. First, there was a shift in psychiatric thinking toward a psychodynamic and psychoanalytic model emphasizing life experiences and the role of socioenvironmental factors. Second, the experiences of World War II appeared to demonstrate the efficacy of community and outpatient treatment of persons with mental illness. Third, the belief that early intervention in the community would be effective in preventing subsequent hospitalization became popular. Fourth, a faith developed that psychiatry could promote prevention by contributing toward the amelioration of social problems that allegedly fostered mental diseases. Fifth, the introduction of psychological and somatic therapies (including, but not limited to, psychotropic drugs) held out the promise of a more normal existence for patients outside of mental institutions. Finally, an enhanced social welfare role of the Federal Government not only began to diminish the authority of State governments, but also hastened the transition from an institutionally based to a community-oriented policy (Grob, 1991).

Winds of change were evident well before the widespread use of psychotropic drugs or the advent of "deinstitutionalization" (an often misunderstood and misleading term). The specialty of psychiatry, long synonymous with institutional care, rapidly changed its character in the postwar era. To be sure, psychiatrists began to find careers outside of public institutions in the interwar decades. But after 1945 there was a mass exodus of psychiatrists from mental hospitals into private and community practice. Within a decade more than 80 percent of the 10,000 members of the American Psychiatric Association (APA) were employed outside of mental hospitals. Their positions were taken by foreign medical graduates with little or no training in psychiatry (Biographical Directory, 1958; Boyd, 1958). Although the APA staff continued to work with public hospitals, they were neither knowledgeable about nor sympathetic toward their institutional brethren and often emphasized the desirability of noninstitutional alternatives. Moreover, most psychiatrists in the community treated large numbers of patients with psychological problems; thus, their contacts with persons who had long-term care needs were sharply reduced. That hospitals had a large proportion of such patients hardly accorded with the self-image of the psychiatrist as an active and successful therapist.

The weakening of the long-established links between hospitals and psychiatrists also was accompanied by a movement to strengthen outpatient and community clinics. Before 1940, such clinics had dealt predominantly with children rather than adults. The postwar enthusiasm for clinics received momentum with the passage of the National Mental Health Act of 1946, which provided grants to States to support existing outpatient facilities or to establish new ones. The ultimate goal, according to Robert H. Felix, first director of the National Institute of Mental Health (NIMH), was one outpatient facility for each 100,000 persons. Although appropriations were modest, their impact was dramatic. Before 1948, more than half of all States had no clinics; by 1949, all but five had one or more. Six years later, there were about 1, 234 outpatient psychiatric clinics, of which about two-thirds were State-supported or aided. Psychiatrists proved staunch proponents of a community-oriented policy, for they insisted that early identification and treatment in outpatient facilities or private offices diminished the need for subsequent hospitalization and were also cost effective (Grob, 1991).

During the 1950's support for a community-based policy increased steadily; the Governors' Conference and Council of State Governments, as well as private foundations such as the Milbank Memorial Fund, played important roles in marshalling support for innovation. In 1954, New York enacted its influential Community Mental Health Services Act, which provided State funding for outpatient clinics; California followed suit shortly thereafter with the passage of the Short-Doyle Act. By 1959, there were more than 1,400 clinics serving about 502,000 individuals, of whom 294,000 were over the age of 18 (Gains in outpatient, 1960; Norman, Rosen, & Bahn, 1962). The expansion of community facilities was accompanied also by new services to schools, courts, and social agencies by nonmedical mental health professionals. This development offered further proof of the degree to which the public sought, if not demanded, access to psychiatric and psychological services in noninstitutional settings. During these years, Robert Felix and his NIMH colleagues used their links with key congressional figures to enhance the policymaking authority of the Federal government as a vehicle to strengthen community policies (Grob, 1991).

Many of the claims about the efficacy of community care and treatment, however, rested on extraordinarily shaky foundations. The presumption was that outpatient psychiatric clinics could identify early cases of mental disorders and serve as alternatives to mental hospitals. The empirical data to validate such assertions, however, were lacking. Indeed, a study of about 500 patients in three California State hospitals during the 1950's found most of the patients unsuited to treatment in clinics (Sampson, Ross, Engle, & Livson, 1958). Data collected by Morton Kramer and his associates at the Biometrics Branch of NIMH found equally serious problems. A community policy was based on the expectation that patients could be treated outside of institutions. Underlying this belief were several assumptions: (1) the patient had a home; (2) the patient had a sympathetic family or other person willing and able to assume responsibility for his or her care; (3) the organization of the household would not impede rehabilitation; and (4) the patient's presence would not cause undue hardships for other family members. In 1960, however, 48 percent of the mental hospital population were unmarried, 12 percent were widowed, and 13 percent were divorced or separated. A large proportion of patients, in other words, may have had no families to care for them. Hence the assumption that patients could reside in the community with their families while undergoing rehabilitation was hardly realistic (Kramer, 1967a, 1967b; Kramer, Taube, & Starr, 1968)

Such findings fell on deaf ears; the rhetoric of community care and treatment carried the day in the 1950's and 1960's. Too often, exaggerated claims were overlooked or ignored. Yet, rhetoric cannot be dismissed so easily: it shaped agendas and debates; it created expectations that in turn molded policies; and it informed the socialization, training, and education of those in professional occupations. From the creation of the Joint Commission on Mental Illness and Health in 1955 and the publication of its influential Action for Mental Health: Final Report of the Joint Commission on Mental Illness and Health 1961 to the passage of the Community Mental Health Centers Act of 1963, the advocates of a community-oriented policy succeeded in forging a consensus regarding the desirability of diminishing the central role of mental hospitals and strengthening community facilities. They were joined by a variety of other individuals and groups. Psychiatric critics (e. g., Thomas Szasz, Thomas J. Scheff) attacked the very legitimacy of the concept of mental illnesses; civil rights advocates identified persons with mental illness as a group systematically deprived of constitutional liberties; and social activists emphasized that institutions such as mental hospitals could never be other than repressive and dehumanizing institutions. The result was a determined and partially successful effort to reshape public policy by diminishing the role of hospitals and enhancing the significance of outpatient and community services (Grob, 1991).

During the 1960's, the attack on the legitimacy of institutional care began to bear fruit. Hospital populations declined rapidly after 1965. This pattern is clearly shown in Figure 1. A shift in thinking had made community care and treatment, at least in theory, an acceptable alternative to institutionalization. Administrative and structural changes within institutions, including open-door policies, informal admissions, and efforts to prepare patients for early release, as well as the introduction of psychotropic drugs, reinforced the faith in the efficacy of community treatment. The passage of Medicaid and Medicare, moreover, hastened the exodus of aged patients from hospitals to chronic nursing homes. The rapid expansion of third-party reimbursement plans stimulated the use of inpatient and outpatient psychiatric services in general hospitals. Ironically, the reduction of the patient population, no doubt, had the effect of improving the lives of those who remained in public mental hospitals.

Nowhere are the changes in the mental health system during the 1960's more visible than in the aggregate data dealing with patient care episodes. In 1955, there were 1,675,352 patient care episodes; 379,000 (22.6 percent) were treated in outpatient facilities, 818,832 (48.9 percent) in State mental hospitals, and the remainder in other institutions. Of 3,380,8188 episodes in 1968, 52.7 percent were treated in outpatient facilities (of which 8 percent were in community mental health centers, or CMHCs), 23.4 percent in State hospitals, and 23.9 percent in other institutions. To put it another way, in 1955, 77.4 percent of episodes were treated in inpatient facilities and 22.6 percent in outpatient settings; 13 years later the respective figures were 47.3 percent and 52.7 percent. In sum, there was a profound shift in the location of services as well as an increase in the rate of episodes. In 1955 there were 1,028 episodes per 100,000; by 1968 this figure had risen substantially to 1,713 (NIMH, 1970, 1980).

The change in the location of services, however, did not mean that public mental hospitals were on the road to extinction and that community outpatient centers and clinics were assuming their functions. On the contrary, it is well known that outpatient facilities grew rapidly because they were used by new groups that in the past had no access to the mental health system and who were, for the most part, not persons with long-term care needs. Thus while the rate of inpatient care episodes at public hospitals declined from 502 to 401 per 100,000 between 1955 and 1968, outpatient care episodes leaped from 233 to 901. In absolute terms, inpatient care episodes at public institutions in the same period fell from 818,832 to 791,819, whereas outpatient care episodes increased from 379,000 to 1, 778,590 (NIMH, 1970, 1980). These data demonstrate that the growth in outpatient services was not at the expense of inpatient services. Many of the changes in the mental health system, in other words, occurred because of the expansion of services and recruitment of a new clientele rather than the substitution of one service for another.

The dramatic growth of outpatient facilities diminished the relative significance of public mental hospitals, which for more than a century had been central to the mental health system. The number of resident patients fell slowly in the period from 1955 to 1965, and more rapidly thereafter. Yet, at the same time, the number of admissions was increasing. In 1955, 178,003 persons were admitted to State and county mental hospitals. A decade later, the figure was 316, 664. The rapid decline in the resident population after 1965 did not alter this pattern; in 1970 there were 384,511 admissions. These figures suggest that an important change in the function of State hospitals had taken place. During the first half of the 20th century, these institutions cared for large numbers of long-term care cases drawn from several categories, including persons with schizophrenia admitted during youth and early maturity and who remained for the rest of their lives, persons with disorders of aging, and persons with sexually transmitted diseases. By the late 1960's, the number of aged and chronic patients began to fall, and mental hospitals then began to provide more short-and intermediate-term care and treatment for persons with severe mental illness (Kramer, 1976).

To be sure, the number of patient care episodes treated in general hospitals (with and without psychiatric units) and Federally funded CMHCs increased, although there were sharp variations from place to place. The available (and imperfect) data, however, indicate that these facilities did not generally treat individuals previously admitted or likely to be admitted to mental hospitals. There were, for example, some striking differences in diagnostic categories. In 1969, State hospitals had a higher proportion of patients with schizophrenic reactions, a group that constituted the core of those with severe mental illness. Nearly 30 percent of their admissions were in this category, while 11 percent were in the organic brain syndrome and 10. 2 percent in the depressive categories. General hospital inpatient services, by way of contrast, treated different kinds of patients. More than a third of their admissions suffered from depressive disorders; schizophrenic reactions accounted for 17.2 percent and organic brain syndromes 6.5 percent (Kanno & Scheidemandel, 1974; Kramer, 1976; NIMH, 1972).

The differences between State mental and general hospitals with specialized units become even clearer from length-of-stay data. Stays in general hospitals were far shorter than those in public mental hospitals (Kanno & Scheidemandel, 1974); in 1975 the mean stay was only 11 days and the median 6.7. The pattern in State mental hospitals differed substantially; a significant proportion of patients were institutionalized for long periods. Even though the number of long-term patients at public institutions fell precipitously after 1965 because changes in funding patterns reduced the number of elderly and long-term care patients, State hospitals remained what three investigators termed "the place of last resort" for perhaps 100,000 individuals for whom no alternative facility was available. Thus, in 1969 the mean stay of discharged patients at public hospitals was 421 days; 6 years later the corresponding figure was 270 days. Median length-of-stay data, however, reveals a quite different situation. In 1970, the median length of stay for admissions (excluding deaths) was 41 days; 5 years later this figure had dropped to 25 days. These data suggest that public institutions continued to treat and care for more persons with severe and long-term illnesses than did any other kind of institution. Indeed, in 1969 and 1975 public institutions accounted for 79.4 and 67.2 percent, respectively, of all days of inpatient psychiatric care (Kramer, 1976).

Hailed as the harbingers of a new era, CMHCs failed to live up to their promise. Admittedly, appropriations fell far below expectations because of the budgetary pressures engendered by the Vietnam War. More important, CMHCs served a different popplation than State hospitals did. Most centers made little effort to provide coordinated aftercare services and continuing assistance to persons with severe and long-term mental illnesses. They preferred to emphasize psychotherapy, an intervention especially adapted to individuals with emotional and personal problems as well as one that appealed to a professional constituency. Even psychiatrists in community settings tended to deal with more affluent persons with neuroses, as compared with persons with long-term mental illnesses.

Changing Federal Policies

During and after the 1970's, the focus of Federal policy shifted dramatically because of a growing perception that substance abuse (particularly drugs and, to a lesser extent, alcohol) represented major threats to the public at large. Beginning in 1968, Congress enacted legislation that sharply altered the role of CMHCs by adding new services for substance abusers, children, and elderly persons. Congress believed that the Community Mental Health Centers Act of 1963 had resolved most of the major problems of persons with mental illness and that greater attention should be paid to other groups in need of mental health services. As the services provided by centers proliferated, the interests of persons with severe and long-term mental illnesses— clearly the group with the most formidable problems— slowly receded into the background.

The inauguration of Richard Nixon in 1969 altered the political environment. Between 1970 and 1972, his Administration worked assiduously to scale back NIMH programs, many of which survived only because of a sympathetic Congress. By 1973, however, the Watergate scandal was preoccupying the attention of the White House, and mental health policy issues receded into the background. Nixon's resignation in the summer of 1974 was welcomed by those concerned with mental health policy issues, if only because he was perceived as an opponent of any significant Federal role in shaping and financing services. In the months preceding and following Nixon's resignation, Congress undertook a reassessment of the CMHC program. The result was the passage of a mental health law in mid-1975 over President Gerald Ford's veto. Yet this legislation— which expanded the role of CMHCs— never addressed the fundamental issue of providing for the basic human and medical needs of persons with severe mental illnesses (Grob, 1994a).

The election of Jimmy Carter to the presidency in 1977 introduced a new element of hope. In one of his first acts, Carter signed an executive order creating the President's Commission on Mental Health to review national needs and make necessary recommendations. Yet, the Commission's final report offered at best a potpourri of diverse and sometimes conflicting recommendations. Eventually, Congress passed the Mental Health Systems Act a month before the 1980 presidential election. Its provisions were complex and, in some respects, contradictory. Nevertheless, the law suggested at the very least the outlines of a national system that would ensure the availability of both care and treatment in community settings (Grob, 1994a).

The Mental Health Systems Act hardly had become law when its provisions became moot. The election of Ronald Reagan to the presidency led to an immediate reversal of policy. Preoccupied with reducing both taxes and Federal expenditures, the new Administration proposed a 25 percent cut in Federal funding. More important, it called for a conversion of Federal mental health programs into a single block grant to the States carrying few restrictions and without policy guidelines. The presidential juggernaut proved irresistible, and in the summer of 1981 the Omnibus Budget Reconciliation Act was signed into law. Among other things, it provided a block grant to States for mental health services and substance abuse. At the same time, it repealed most of the provisions of the Mental Health Systems Act. The new legislation did more than reduce Federal funding for mental health; it reversed nearly three decades of Federal involvement and leadership. In the ensuing decade, the focus of policy and funding shifted back to the States and local communities, thus restoring in part the tradition that had prevailed until World War II. The transfer and decentralization of authority, however, exacerbated existing tensions; Federal support was reduced at precisely the same time that States were confronted with massive social and economic problems that increased their fiscal burdens (Grob, 1994a).

The Paradox of Deinstitutionalization

Disagreements over national mental health policy were but one development that had major repercussions. Equally significant, States during and after the 1970's accelerated the discharge of large numbers of persons with severe and persistent mental illnesses from public mental hospitals. The origins of "deinstitutionalization"— a term that is both imprecise and misleading— are complex. Prior to World War II, responsibility for care and treatment had been centralized in public asylums. Under the policies adopted during and after the 1960's, however, responsibility was diffused among a number of different programs and systems. The failure of CMHCs to assume the burdens previously shouldered by State hospitals, for example, magnified the significance of the medical care and entitlement systems. General hospitals with and without psychiatric wards began to play an increasingly important role in treating persons with mental illnesses. Because such persons tended to be unemployed and, thus, lacked either private resources or health insurance, their psychiatric treatment often was financed by Medicaid. Similarly, responsibility for care (i. e., food, clothing, and shelter) slowly was subsumed under the jurisdiction of Federal entitlement programs. A paradoxical result followed. The fragmentation of what had once been a unified approach to mental illnesses was accompanied by an expansion of resources to enable persons with serious mental illnesses to reside in the community.

During and after the 1960's, deinstitutionalization was indirectly sanctioned by the judiciary when Federal and State courts began to take up long-standing legal issues relating to persons with mental illnesses. The identification of these new legal issues had significant consequences for psychiatrists and persons with mental illnesses. The traditional preoccupation with professional needs was supplemented by a new concern with patient rights. Courts defined a right to treatment in the least restrictive environment; shortened the duration of all forms of commitment and placed restraints on its application; modified the right of psychiatrists to make purely medical judgments about the necessity of commitment; accepted the right of patients to litigate both before and after admission to a mental institution; and defined a right of a patient to refuse treatment under certain circumstances. The emergence of mental health law advocates tended to weaken the authority of both psychiatrists and mental hospitals, and conferred added legitimacy to the belief that protracted hospitalization was somehow counterproductive and that community care and treatment represented a more desirable policy choice (Grob, 1994a).

Judicial decisions, however significant, merely confirmed existing trends by providing a legal sanction for deinstitutionalization. Some knowledgeable figures recognized potential problems and voiced concern. Nevertheless, the pattern of discharging patients from mental hospitals after relatively brief stays accelerated after 1970 because of the expansion of Federal entitlement programs having no direct relationship with mental health policy. States began to take advantage of a series of relatively new Federal initiatives that were designed to provide assistance for a variety of disabled groups and thus facilitate their maintenance in the community.

The elderly were among the first to be affected by new Federal policies. Immediately following the passage of Medicaid in 1965, States began to shift the care of elderly persons with behavioral symptoms from mental hospitals to chronic care nursing facilities. Such a move was hardly the result of altruism or a belief that the interests of aged persons would be better served in such institutions. On the contrary, State officials were predisposed to the use of nursing homes because a large part of the costs were assumed by the Federal government. The quality of care in such facilities (which varied in the extreme) was not an important consideration in transferring patients. Indeed, the relocation of elderly patients from mental hospitals to extended care facilities often was marked by increases in the death rate. Moreover, many nursing homes provided no psychiatric care. When Bruce C. Vladeck published his study of nursing homes in 1980, he selected as his book title Unloving Care: The Nursing Home Tragedy.

During the 1960's the population of nursing homes rose from about 470,000 to nearly 928,000, largely as a result of Medicaid. A study by the General Accounting Office (GAO) in 1977 noted that Medicaid was a large purchaser of mental health care, the principal Federal source of funding for care of persons with mental disability and a major factor in deinstitutionalization (GAO, 1977). By 1985, nursing homes had over 600,000 residents diagnosed with mental illnesses; the cost of their care was over $10. 5 billion, a large proportion of which was paid for by Medicaid. The massive transfer of large numbers of elderly patients who behaved in abnormal ways was not controversial, if only because such individuals posed no obvious threats to community residents. Designed to provide services for the elderly and indigent, therefore, Medicaid (as well as Medicare) quickly became one of the largest mental health programs in the United States (GAO, 1977; Johnson, 1990; Rice, Kelman, Miller, & Dunmeyer, 1990).

Other Federal programs had an equally profound effect on nonelderly persons with mental illnesses. In 1956, Congress had amended the Social Security Act to enable eligible persons, age 50 and over, to receive disability benefits. The Social Security Disability Insurance (SSDI) program continued to become more inclusive in succeeding years and ultimately covered persons with mental disabilities. In 1972, the Social Security Act was further amended to provide coverage for individuals who did not qualify for benefits. Under the provisions of Supplemental Security Income for the Aged, the Disabled, and the Blind (more popularly known as SSI), all those whose age or disability made them incapable of holding a job became eligible for income support. This entitlement program was administered and fully funded by the Federal government; its affiliation with Social Security had the added virtue of minimizing the stigmatization often associated with welfare. SSI and SSDI encouraged States to discharge persons with severe and persistent mental illnesses from mental hospitals, since Federal payments would presumably enable them to live in the community. Those who were covered under SSI also became eligible for coverage under Medicaid. In addition, public housing programs and food stamps added to the resources of persons with mental illnesses residing in the community (Johnson, 1990; Public Law 92-603, 1972).

The expansion of Federal entitlement programs hastened the discharge of large numbers of institutionalized patients during and after the 1970's. This trend was reflected in the changing pattern of mental hospital populations. In the decade following 1955, the decline in inpatient populations was modest, falling from 559,000 to 475,000. The decreases after 1965 were dramatic: between 1970 and 1986, the number of inpatient beds in State and county institutions declined from 413,000 to 119,000, and in the 1990's fell well below 100,000. Length-of-stays dropped correspondingly. Yet, State hospitals remained the largest provider of total inpatient days of psychiatric care; their patients were disproportionately drawn from the ranks of the most difficult, troubled, and violence-prone (Grob, 1997).

In theory, the combination of entitlement programs and access to psychiatric services outside of mental hospitals should have fostered greater State financial support for community programs. The presumption was that a successful community policy would eventually permit the consolidation of some mental hospitals and closure of others, thus facilitating the transfer of State funds from institutional to community programs. In practice, however, the State mental hospital proved far more resilient than its critics anticipated. Some had powerful support among community residents and employees who feared the dramatic economic consequences that would accompany closure. A shrinking inpatient census, therefore, sometimes led to rising per capita expenditures, since operating costs were distributed among fewer patients. Equally important, there remained a seemingly irreducible group of individuals who were so disabled that institutional care appeared to be a necessity.

In retrospect, mental health policy changed dramatically after 1965, but not in the manner envisaged by those active in its formulation. After World War II, there was a decided effort to substitute an integrated community system of services for traditional mental hospitals. The system that emerged in the 1970's and 1980's, however, was quite different. First, mental hospitals did not become obsolete even though they lost their central position. They continued to provide both care and treatment for the most severely disabled part of the population. Second, community mental health programs expanded dramatically, and inpatient and outpatient psychiatric services became available in both general hospitals and CMHCs. A significant proportion of their clients, however, represented new populations that did not fall within the traditional categories. Finally, a large part of the burden of supporting persons with severe mental illness in the community fell on a variety of Federal entitlement programs that existed quite apart from the mental health care system. Since the 1970's, therefore, such persons have come under the jurisdiction of two quite distinct systems— entitlements and mental health— that of-ten lacked any formal programmatic or institutional linkages (Grob, 1994a).

Whatever its contradictory and tangled origins, deinstitutionalization had positive consequences for a large part of the Nation's population with severe and persistent mental illnesses. Data from the Vermont Longitudinal Research Project (begun in the mid-1950's) offered some dramatic evidence that individuals with severe mental illness who were provided with a range of comprehensive services could live in the community. The results of this experiment indicated that two-thirds "could be maintained in the community if sufficient transitional facilities and adequate aftercare was provided." Similar longitudinal studies in the United States, Switzerland, and Germany came to similar conclusions. A variety of other mental health service demonstration projects supported by private foundations and Federal agencies (e. g., the Robert Wood Johnson Foundation, NIMH, the Agency for Health Care Research and Quality, and CMHS) have confirmed the effectiveness of a system that provides employment opportunities, supportive housing, social supports, treatment of individuals with both mental illness and substance abuse diagnosis, and the diversion of persons with mental illnesses from jails into integrated treatment facilities. That individuals with severe mental disorders prefer and do better in community settings is clear; access to economic resources (particularly vocational rehabilitation) and empowerment provide a feeling of mastery rather than a sense of dependency (Goldman, 1999; Harding, 1986; Rosenfield, 1992).

The Dilemma of "Young Adult Chronic Patients"

Under the best of circumstances, deinstitutionalization would have been difficult to implement. The multiplication of programs and absence of formal integrated linkages, however, complicated the task of both patients and those responsible for providing care and treatment. Moreover, the decades of the 1970's and 1980's were hardly propitious for the development and elaboration of programs to serve disadvantaged populations such as persons with severe and persistent mental illnesses. The dislocations and tensions engendered by the Vietnam War, an economic system that no longer held out as great a promise of mobility and affluence, and the rise of antigovernment ideologies all combined to create a context that made experimentation and innovation more difficult. The founding of the National Alliance for the Mentally Ill in 1979 helped, in part, to redress the balance. It brought together families of persons with mental illnesses in an advocacy organization that began to play an increasingly important

role in the politics of mental health during and after the 1980's.

As a policy, deinstitutionalization was based on the premise that the population found in mental hospitals was relatively homogeneous. The first major wave of discharges came after 1965 and occurred among a group of individuals who had been institutionalized for relatively long periods or else had been admitted later in their lives. This phase was not controversial nor did it create difficulties, since few of these individuals seemed to pose a threat to others.

After 1970, a quite different situation prevailed because of basic demographic trends in the population as a whole and changes in the mental health service system. At the end of World War II, there was a sharp rise in the number of births, which peaked in the 1960's. Between 1946 and 1960, more than 59 million births were recorded. The disproportionately large size of this age cohort meant that the number of persons at risk for developing severe mental disorders was very high. Moreover, younger people tended to be much more mobile than the general population.

At the same time that the cohort born after 1945 was reaching its 20's and 30's, the mental health service system was undergoing fundamental changes. Prior to 1970, persons with severe and persistent mental disorders were generally cared for in State hospitals. If admitted in their youth, they of-ten remained institutionalized for decades, or else were discharged and readmitted. Hence, their care and treatment was centralized within a specific institutional context, and, in general, they were not visible in the community at large. Although persons with long-term care needs were always found in the community, their relatively small numbers posed few difficulties and in general did not arouse public concern.

After 1970, however, a subgroup of persons with mental illnesses— composed largely of young adults— were adversely affected by the changes in the mental health service system. Such persons were rarely confined for extended periods within mental hospitals. Restless and mobile, they were the first generation of psychiatric patients to reach adulthood within the community. Although their disorders were not fundamentally different than their predecessors, they behaved in quite different ways. They tended to emulate the behavior of their age peers who were often hostile toward conventions and authority. The young-adult population with long-term care needs exhibited aggressiveness, volatility, and noncompliance. They generally were diagnosed with schizophrenia, although affective disorders and borderline personality disorders were also present. Above all, they lacked functional and adaptive skills. Complicating the clinical picture were high rates of alcoholism and drug abuse among these patients, which only exacerbated their volatile and noncompliant behavior. Virtually every community experienced the presence of these young adult individuals on their streets, in emergency medical facilities, and in correctional institutions. Recent estimates have suggested that perhaps a quarter to a third of the single adult homeless population have a severe mental disorder. Many have a dual diagnosis of severe mental illness and substance abuse and were often caught up in the criminal justice system (Grob, 1994a).

Deinstitutionalization was largely irrelevant to many of the young patients who were highly visible after 1970. They had little or no experience with prolonged institutionalization, and, hence, had not internalized the behavioral norms of a hospital community. The mobility of such individuals, the absence of a family support system, and programmatic shortcomings complicated their access to such basic necessities as adequate housing and social support networks. The dearth of many basic necessities of life further exacerbated their severe mental disorders. Ironically, at the very time that unified, coordinated, and integrated medical and social services were needed to deal with a new patient population, the policy of deinstitutionalization had created a decentralized system that often lacked any clear focus and diffused responsibility and authority (Grob, 1994b, 1997).

Conclusion

A superficial analysis of the mental health scene in the recent past can easily lead to depressing conclusions. The combined presence of large numbers of young persons with long-term care needs, as well as larger numbers of homeless people undoubtedly reinforced feelings of public apprehension and professional impotence. Indeed, the popular image of mental illnesses and the mental health service system was often shaped by spectacular exposés in the media— visual and printed— that seemed to reveal sharp and perhaps irreconcilable tensions. In the popular images could be seen the conflict between absolutist definitions of freedom and other humanitarian and ethical principles, as well as the concerns that the well-being, if not the very safety, of the community seemed endangered.

The image of deinstitutionalization so often portrayed in the press and on television, nevertheless, represented a gross simplification that ignored a far more complex reality. The popular image of this population using drugs, wandering the streets of virtually every urban area, and resisting treatment and hospitalization was true for only a subgroup of a much larger population of persons with mental illnesses. Many of these persons have made a more or less successful transition to community life as a result of the expansion of Federal disability and entitlement programs (Koyanagi and Goldman, 1991). That major problems within the mental health system persist is indisputable. Mechanic (1991) insists that a variety of different strategies— including the integration of assertive community treatment, approaches that unified diverse sources of funding and directed them toward meeting needs of disabled persons, strong local mental health authorities, and rational reimbursement structures— offered at least the potential for improvement (Mechanic, 1991). Only the future will reveal whether such a potential can become a reality.

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