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Seriously Mentally Ill: Moving Away from Institutions to the Community

December 17, 2013 by Gina Putt 3 Comments

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Homelessness is related to deinstutionalization. Image by mimicry.

Homelessness is related to deinstutionalization. Image by mimicry.

In a brief span of time, police shot two mentally ill individuals – would more availability of psychiatric beds have made a difference?

On December 16, 2013 The Salt Lake Tribune reported that the police shot a knife-wielding man. On December 14, 2013, SFGate reported that police in Honolulu shot a man with a blade attached to a twelve-foot pole.

Why were these men not obtaining mental health services?  Perhaps part of the blame lies in a system that has tilted too far in favor of deinstiutionalization.

The Move Away from Institutions to Wrap-Around Care

The number of mentally ill individuals housed in institutions in the United States peaked in the mid-1950s at 560,000 people.  After  philosophical questions about the nature of mental illness, the establishment of better therapies, more potent medications, and the rise of outpatient mental health centers, that number dropped precipitously, with more and more seriously mentally ill people living in the community.

The number of psychiatric beds declined precipitously.  “A March 2008 report by the Treatment Advocacy Center reveals that for every 20 public psychiatric beds that existed in the US in 1955, only one such bed existed in 2005.”




In the period from 1993 to 2003, the cost of treatment for people with a serious mental illness has shifted from hospitals to drug treatment.  The National Institute of Mental Health’s website notes, “the percentage of payments going to specialty hospitals and specialty units within general hospitals decreased notably. During the same period of time, the percentage of mental health payments for retail prescription drugs increased.”  Only 7.5% of the cost for mental health was spent on inpatient treatment in 2008.

In Nebraska,  the population of three mental hospitals housing 2000 to 2500 people has been reduced to two hospitals housing about 200 individuals. According to Jim Jenson, Nebraska state senator in 2005, a bill was passed to provide “subsidized housing and for wrap-around services that will enable people with mental illnesses to live independently and productively. Recovery is the goal.”  Subsidized housing, such as Section 8 programs, reduce the amount paid for rent and utilities while wrap-around services include access to clinics, case workers and other supportive services.

The Risks of Deinstutionalization: Homelessness, Imprisonment, Overuse of Emergency Rooms

Has the movement toward deinstitutionalization has gone too far?  Recent decades have been dominated by discussions of civil rights and budget reductions rather than patient and public safety.  Mentally ill individuals who are not yet diagnosed, or who are not responsive to medication  or who refuse it, are at high risk of homelessness, of overburdening local emergency rooms, or being incarcerated, according to Treatment Advocacy Center.  No one wants to go back to a time when there was a psychiatric bed for every mental patient, but more beds could relieve the burden on emergency rooms and police, as well as provide more appropriate care.

Researchers determined that 50 psychiatric beds per every 100,000 individuals is the minimum to serve a population.  According to Treatment Advocacy Center, “Eight states still don’t have assisted outpatient treatment and many states are in need of additional community mental health services, making 50 public psychiatric beds per 100,000 people a minimum requirement… In 32 states the bed shortage was critical or severe, 42 states had less than half the minimum number of beds needed, and six states had less than 20 percent of the minimum beds needed to provide adequate care..”

The Need for Balance

In 1998, the Treatment Advocacy Center published an article titled, “The Devil in Deinstitutionalizing” which said, “ many proponents of deinstitutionalization now admit that they were over-idealistic at the outset, and grossly underestimated the challenge of helping the mentally ill manage themselves outside a controlled setting, the idealism of the sixties gradually has given way to more realistic assessments and approaches.”   Although the last fifteen years since the piece was published have brought about better psychiatric medications, the shrinking number of psychiatric beds still poses dilemmas.  Civil rights are important.  Being frugal with public funds is important. Safety is important.  It is up to us and our legislatures to find a balance.

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Filed Under: Headlines, Social Science Tagged With: criminal justice system, de-institutionalization, homelessness, institutionalization, mentally ill, psychiatric beds, schizophrenia, SMI

Resources for this article

Treatment Advocacy Center. Severe Shortage of Psychiatric Beds Sounds National Alarm Bell . (2011). Accessed on December 17, 2013


Paige, Sean . NEWS The Devil in Deinstitutionalizing . (1998). Treatment Advocacy Center. Accessed on December 17, 2013


PBS. American Experience--Timeline: Treamtents for Mental Illness. (2002). Accessed on December 17, 2013


McFall, Michael. Man shot by West Valley City cop had knife, was walking in traffic. (2013). The Salt Lake Tribune. Accessed on December 17, 2013


SFGate. Police fatally shoot man at Waipahu home. (2013). Accessed on December 17, 2013


National Institute of Mental Health. Outreach Partnership Program 2005 Annual Meeting. (2005). Accessed on December 17, 2013


National Institute of Mental Health. Change in Mental Health Payments by Provider (1993 vs. 2003) . Accessed on December 17, 2013




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Comments

  1. HaroldAMaio says

    December 17, 2013 at 10:11 pm

    deinstitutionalization—

    Sometimes the meanings of euphemisms get
    lost. “Deinstitutionalization” was a euphemism for closing institutions to
    remove their costs form state governments’ budgets. The costs did not disappear,
    they transferred. Individuals now bear those costs, and communities unable to
    meet their needs.

    In the period from 1993 to 2003, the cost of
    treatment for “the” mentally ill has shifted from hospitals to drug
    treatment—

    “The” mentally ill is all to reminiscent of
    “the” Blacks. I am sure it is an error.

    The number of mentally ill individuals housed
    in institutions in the United States peaked in the mid-1950s at 560,000
    people—

    Hospitals do not “house” patients, institutions do. The change in
    vocabulary is welcome.

    Reply
    • Gina Putt says

      December 18, 2013 at 6:50 am

      Thank you for your thoughtful comments. Where I work in psychiatric case management, we view state institutionalization as an unfortunate, but least harmful, option for providing housing for those with the most serious and unstable conditions. Stable housing is very much part of treatment. In my view, if someone is unable to live independently or with supportive services, and is living in a state hospital rather than on the streets, it is the better of two unfortunate outcomes.
      As a writer, I look for short phrases. Of course in the industry, “the mentally ill” is discouraged. I have changed it to “those with mental illness.” I must say that as a person that has struggled with some mental health issues myself, I do not see “the depressed” as a problem, but I know that others see it as a label that is too stigmatizing. Too bad as we don’t usually see phrases like “The diabetics in the study…” as worthy of attention.

      Reply
      • HaroldAMaio says

        December 18, 2013 at 9:14 am

        I do not employ the term “stigmatizing”, rather I ask , “What do you mean by that?” I then note the responses and employ those words.
        I agree, there will always be people whose needs are beyond those a community offers. I wish, though, the we had a term other than “hospital”. I know of no state mental institution that rose to the level of that term.

        Reply

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About the Author

Gina Putt

Gina Barrett Putt holds a Master's degree in Sociology from the University of South Alabama and has taught both psychology and sociology at the college level. She possesses experience in housing, gerontology, mental health, and ... Read Full Profile

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