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Deinstitutionalization, Transinstitutionalization and Reinstitutionalization

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Martin Sellers
September 21, 2021

Anyone who studied Public Administration in the ‘60s and ‘70s quickly became aware of the term “deinstitutionalization.” Regardless of how you came across information on the history of deinstitutionalization, politicians and academics agree that mentally ill individuals were released from mental health institutions (asylums) in ever increasing numbers beginning in about the 1950s. The opening of institutional flood gates occurred with the development and widespread availability of antipsychotic drugs, the expansion of community health centers funded by federal block and formula grants and increased research findings about causation. Scrapping of large mental health facilities and the reduction of the number of patient beds nationwide was understood at the time as a good thing, helping individuals back into the community to be near family, reducing the cost of patient care and reducing the building and maintenance of large mental health facilities. All of this has led us to a public health (public administration) crisis.

What Happened?

When mental health institutions began releasing patients, many returned to family in unprepared households in towns and cities. Many became homeless, and in most cases, became involved in crime and addicted to drugs, eventually ending up in prison or on the street. As a comparison, approximately 4% of the general population in the United States grapple with serious mental illness (schizophrenia, bipolar condition, depression, etc.).  About half of 1.8 million prisoners in United States jails and prisons have serious mental health issues. 50% of those also have drug addiction problems. President Kennedy, in 1963, submitted legislation to Congress entitled The Community Mental Health Act. That legislation helped to eliminate large mental health institutions, brought into the spotlight community health centers (mostly outpatient) and provided funding for drug therapy and rehabilitation programs. In 1965, the Medicaid program was established, which reduced funding for long-term care facilities, making the number of beds for institutionalized patients dramatically smaller. Many patients went to the streets, though some were sent to medical hospital mental health wards. The vast majority, however, ended up in jails (local level) or prisons (state/federal).

Transinstitutionalization is a term used to describe moving institutionalized people from one type of institution to another—in this case, from mental health facilities to jails and prisons. The facts today show that antidepressant drugs do not work well for the severely mentally ill, nor do antipsychotic drugs entirely help mental patients maintain mental health. In prisons, the mentally ill are kept mainly in isolation units or, if in the general population, exploited for money and sex. Closing mental health facilities pushed patients to communities that were and still are unprepared and ill-equipped to keep them. In effect, the federal government pushed responsibility from the national government to the state and local governments and then from state and local governments to the prison system.

Who are the Incarcerated Mentally Ill?

The connection between mental illness and homelessness, incarceration and suicide is very powerful. Twice as many individuals who are incarcerated have severe mental conditions as compared to the general population. The Bureau of Justice Statistics indicates that 25% of jailed mentally ill persons have returned to prison at a rate three times higher than other inmates. Police do not have options for where to take mentally ill persons who have committed crimes. Nor do they have the training for working with them or helping them to find care and refuge. Jails and prisons do have programs for the mentally ill. However, it has been found that mentally ill prisoners do not do well in confinement, away from family and without proper care. They do better in a protected space, where others are being treated, where the correct medications are available and monitored and where case plans are developed and closely followed by medical professionals.

End of Sentence

The public administration of care for the mentally ill cannot continue to be the responsibility of local communities or the prison system. Mentally ill persons should have care and support monitored. They should also be tracked for drug use, living conditions, family support and strides toward rehabilitation. National and state healthcare agencies do well in collecting and maintaining information/statistics on persons, locations and status. Inmates that are determined at intake to have mental illnesses must be afforded the care they need from health institutions, not the prison system. Careful health assessment at the front end of court processing, during prison intake and while in prison, is of paramount importance. Mental illness diagnoses should place persons in treatment services that can handle the variety of mental illnesses that exist. There is a need nationally for more treatment beds, which may mean bringing back some of the large mental health institutions (reinstitutionalization), building or transforming structures into long-term care facilities or at least providing hospitals with more funding. The court-health-prison industry must maintain records, track prisoner mental illness and monitor those who leave incarceration. This will enable prisons and jails to return to their real purpose as rehabilitation facilities. Mentally ill criminals need a different type of rehabilitation than that which prison provides!

Author: Martin P. Sellers, PhD, MPA, MBA, is Dean of the School of Arts, Humanities, and Social Sciences at Lincoln Memorial University (LMU) in Harrogate, Tennessee. He led the creation of the MPA program at LMU in 2015 which went fully online in 2019. Before academics, he worked in all four levels of government, city, county, state and national, including a stint with the US Department of Agriculture. In addition, during a year as Dean of Research at LMU, he was able to encourage collaboration between diverse groups and develop pathways for collaborative scholarship. He may be reached at [email protected] and @martysellers.

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One Response to Deinstitutionalization, Transinstitutionalization and Reinstitutionalization

  1. Michael Abels Reply

    September 26, 2021 at 10:19 am

    The tragedy of our public mental health system, referred to as transinstitutionalization, is a reflection of the dysfunctional collapse of public programs that results when budgetary cost is prioritized over goal accomplishment.
    In the 70s the federal block grant program (Title XX) designed to address deinstitutionalization of public mental health hospitals allowed local communities to create after care, job training, transportation and a range of programs and services oriented to allowing people leaving public mental health hospitals to productively live in our communities. Then, as so often happens with public social programs, the demand to reduce the federal budget resulted in the elimination of Title XX program and the services supporting deinstitutionalization. So homelessness and incarceration became the outcome of our failed political system.
    So the tragedy created was: institutionalization to deinstitutionalization supported through federal funding- elimination of federal funding and closing of community mental health programs resulting in homelessness becoming a national problem and the prison system becoming a major industry.
    The collapse of our community mental health system was a direct outcome of the inability of our political system to tie desired program outcomes to budgetary funding.

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