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Mental Hospital and Deinstitutionalization

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Kelly Beall

on 1 May 2013

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Transcript of Mental Hospital and Deinstitutionalization

Mental Hospitals and Deinstitutionalization Kelly Beall
Sam Bomber
Bailey Dvorak
Cassie Vaningan
Jessica Anderson State mental Hospitals are much less visible to the public eye than they used to be
Deinstitutionalization can mean several different things:
the shift of patients out of state hospitals
the closing of state hospitals
the shift of the state hospital from a central role to a more peripheral role in the mental health system
the declining legitimacy of the state mental hospital as the taken-for-granted caregiver for the seriously mentally ill Introduction Deinstitutionalization caused change in four major categories:
Decline in residents
Closing of hospitals
Addition of outpatient facilities
Changes in hospitals Process of Deinstitutionalization Major criticisms began after WWII
Continuum theory of mental illness became more popular
National Institute of Mental Health (NIMH) gave a voice to the federal government
Media played a huge role in voicing the opinions of critics
Did not prevent the construction of more hospitals
The Kennedy Family voiced discontent with the mental health field based on experiences with a relative Criticisms of State Mental Hospitals A combination of powerful political and economic forces lead to the social movement of deinstitutionalization
Most profound and widespread reforms in American History, a social movement spurred by first hand accounts and from the media with movies such as One Flew Over the Cuckoo's Nest
Deinstitutionalization became a form of public policy, with not only patients but doctors and the general public behind it History of Deinstitutionalization The Social History of the State Mental Hospital Several institutions opened in the 18th century to provide shelter or confine individuals who were "deprived of their reason"
Private institutions and state institutions shared similar philosophies and roles before the Civil War
Hundreds of institutions opened during the 19th century
Reformers were able to shift public care of the insane from "poorhouses and county facilities to state hospitals"
A decline in the number of almshouses, growth of state fiscal capacity, amount of time since statehood, competition for votes
Reflection of the increasing ability and need of states to control deviant and dependent populations Seven Factors for the Growth of Hospital Populations in the 20th Century General population growth
Aging of the general population
Constant pressures of overcrowding and need exceeding capacity
Public and professional confidence in, and willingness to utilize, mental hospitals
Broader conception of mental illness
An increasingly long duration of stay
Decreased tolerance for deviant behaviors and possibly higher rates of mental illness How does the structure of state mental hospitals and the interaction between the patients and staff compare to those in a private hospital such as the one portrayed in Girl, Interrupted? Does either environment seem better suited for helping patients recover from certain forms of mental disorder? One Flew Over the Cuckoo's Nest
Discussion Question Criticisms of State Mental Hospitals Many studies were conducted by sociologists examining the organization of publicly-funded hospitals
Many criticisms lacked empirical data
Most criticisms received attention because of their emotional appeal, not because of their logical, supported arguments
Stories of forced sterilization, unsanitary conditions, and a lack of treatment caused public outrage The Formation of the Joint Commission on Mental Health and Illness bill was signed by President Kennedy in 1963
Attributed to Mental Health Care, the bill was directed to try and keep the mentally ill closer to their communities
This brought on a new phase of mental health care where the community had more direct access to care and patients
Governments gave incentives to relegate to communities with the expansion of Medicare, Medicaid, and Social Security benefits in the 1960s
This was done by the states and federal government, giving more funding to general hospitals History of Deinstitutionalization Other factors in change were the introduction of psychopathic drugs, which got patients back in the communities more quickly, trying o lead their lives normally
The court system had a strong impact as well
Set standards of care for patients
Set a principle of how patients can be used, with and without consent
This lead to the changing roles in the state mental hospitals History of Deinstitutionalization Was this public policy a failure?
State hospitals were and still can be the organization that deals with the seriously mentally ill
The state was the one that gave the mental health sector a backbone from the turn of the century until the 1960s
Deinstitutionalization has broad consequences, including
Social and financial burdens
Greater emphasis on communities for the mentally ill
General hospitals expansion
More homeless and untreated patients History of Deinstitutionalization Decline in Residents From 1950 to 1995, the average number of hospital residents fell from 2,000 to less than 500
Occurred in two phases
Early period - "opening the back door"
Patients released more quickly
Quicker treatment methods to avoid prolonged hospitalization
Later period - "closing the front door"
Admission policies became more restrictive
Mental hospitals increased numbers in psychiatric units, decreasing numbers in mental hospitals Decline in Residents From 1970-1992 the number of specialty mental health organizations, number of organizations with inpatient services, outpatient services and partial care services nearly doubled, while state mental hospitals with each of these services decreased
Patient care episodes receiving assistance from specialty care organizations rose from 2 million to 9 million
From inpatient to ambulatory (outpatient and partial care)
Problems with deinstitutionalization
Lack of coordination with community mental health centers
No plan for aftercare for those released
Psychiatric ghettos near hospitals Closings of State Mental Hospitals Approximately 40 state hospitals closed between 1960 and 1990, according to most recent data
Several states opened new state hospitals during this period as well
Estimated 280 openings in 1990
Many hospitals were renamed because of the stigma associated with their old names
Buffalo State Asylum for the Insane (1880) to Buffalo State Hospital (1890) to Buffalo Psychiatric Center (1974-current)
Even with the decline and pressure to close state hospitals, almost as many exist today than have ever existed in American history Changes in State Hospitals Almost all of the several hundred state hospitals experienced the same journey when going through deinstitutionalization
They went from stable state hospital during first half of 20th century to a somewhat rapid changing institution
In the final phase, the hospital itself became stigmatized and was seen as a last resort for seriously mentally ill people and as an employer in public psychiatry
As the stigma increased, the state hospitals became largely invisible to both the public and those who were concerned with the mental health policies
State hospitals went through considerable turmoil and conflict during desinstitutionalization, which played a big role in a changing mental health care sector Patient Costs, Ratios, and Accreditation The three indicators used to compare and assess the amount of change in state hospitals: daily patient costs, ratio of employees to residents, and accreditation (authorization/qualification)
One of the few researchers to actually examine the changes, Mechanic (1989), observed that public mental hospitals were transformed from custodial care (protective) to active treatment
Mostly because staff-patient ratios “improved enormously”
The average expenditure per patient increased from $4,359 to $31,000
Between 1970 and 1982 the average number of patients per employee reduced from 1.7 to .7
In 1988, Hadley and McGurrin reported data from 1983 on accreditation of 216 state psychiatric hospitals
63.4% were accredited
That is more than double the rate of the 30 years before! Is Accreditation Most Important? However, accreditation is only one measure of the quality of care in state hospitals
In 1996 there was an unannounced visit by an outside agency, the New York State Commission on the Quality of Care for the Mentally Disabled
They compared the living standards in state hospitals to those in prisons
The Commission did notice high quality care for the patients, but also witnessed other negative aspects as well:
Severe overcrowding
Neglect of basic cleanliness
Inadequate clothing
Lack of privacy
Restricted access to drinking water and personal belongings
Endless hours of boredom
These conditions would not meet standards which courts have mandated for incarcerated people
These conditions denied the human dignity of patients in the state hospitals The Aftermath: Rise of Community Mental Health The objective of maintaining the greatest degree of freedom, self determination, autonomy, dignity, and integrity of body, mind, and spirit for the individual while he or she participates in treatment or receives services~ Cater administration commission on mental health
“least restrictive setting” frequently turns out to be a cardboard box, a jail cell, or a terror filled existence plagued by both real and imaginary enemies.
Estimated 150,00 homeless and 159,000 incarcerated have serious mental illness The Aftermath: Deinstitutionalization Among most central was vast increase in the number and types of drugs brought into use in the cure of mentally ill people (Grob, 1994)
Interest shifted from administrative psychiatry to biopsychiatry, allowing for easier out patient treatment. The Aftermath: Homelessness Bachrach (1992) asked how much of the homeless population suffers from chronic mental illness?
Major conceptual problems: defining homelessness, assessing mental illness among homeless people distinguishing between homelessness and mentally ill and other populations
Despite these problems 33-50% of people currently experiencing homelessness are estimated to be mentally ill, and between 22-57% of seriously mentally ill individuals are homeless The Aftermath: Continuity of Care Post Deinstitutionalization care of people with serious mental illness are far less structured
Deinstitutionalization was accompanied by a dramatic rise in for-profit psychiatry
Cases of skimming a profitable client, Dumping unprofitable patients, “wallet biopsies” in which financial resources and insurance restrictions determine care
For some patients community care was major improvement over life in state hospital
Deinstitutionalization challenged involuntary commitment The Aftermath: Transinstitutionalization As state hospital census declined during deinstitutionalization, state prisons and local jail were expanding dramatically and many mentally ill individuals were incarcerated rather than hospitalized or treated in community settings
Lamb (1997) reported on “institutes for mental disease”
Patients had many characteristics of the state hospital populations
Lower cost per day than state hospital
However Lamb reported rising problems with patient behavior and provision of treatment and rehabilitation As the number of available beds decreased during the period of deinstitutionalization, the number of prisoners increased. Conclusions The state mental hospital is the pivot around which public policy about seriously mentally ill people has revolved (Dowdall, 1996)
Most sociologist have ignored the state mental hospital during deinstitutionalization and the new role in a specialty mental health system
Far from disappearing from the institutional scene, the state hospital is “down but not out” becoming a place of last resort( Gronfein, 1989)
State hospitals remain a central challenge of mental health systems Think of examples of institutionalization, depersonalization, alienation, and dehumanization shown in the film. Do you think the potential risks associated with long residency in mental hospitals outweigh the potential benefits? In what situations might hospitalization be preferable to community or home care? One Flew Over the Cuckoo's Nest
Discussion Question
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