Today, the dehumanizing asylums that were a part of America’s earlier history no longer exist. Now, reformed state hospitals are psychiatric hospitals run by state governments, and they are not simply repositories for unwanted people. These hospitals are focused on short-term care, and people are hospitalized only if they pose a significant threat to themselves or others (Spielman et al., 2020). Lengthy psychiatric hospitalizations occur only under specific circumstances and with careful safeguards, as discussed in Chapter 9. People are not legally locked up in institutions simply because they experience a mental disorder.

In the wake of deinstitutionalization, many people with mental disorders were able to live happier and more fulfilling lives, with greater dignity and independence than would have been possible during the heyday of state hospitals. These are people who were able to secure sufficient housing, treatment, and community support; for these people and their loved ones, deinstitutionalization was an enormous victory.

Inadequate Community Alternatives

However, as we have learned, the story of deinstitutionalization is not an entirely happy one. Lack of adequate community opportunities, care, and support for people with mental disorders has led to new challenges. There are not enough community-based mental health centers, and they are often in need of resources. Funding is an often-cited issue, but underfunding is not the only problem. Staffing can be difficult as well, with not enough dedicated professionals entering and staying in critical behavioral health fields. Behavioral health is a broad term that includes all mental health and substance use care and treatment. Behavioral health professionals can include therapists, social workers, medical providers, and others who treat people with mental disorders and mental health problems. A recent government report from Oregon, which has a very high rate of unmet behavioral health needs, outlines numerous problems contributing to staffing shortages, including an inadequate workforce overall; low numbers of providers of color in all workforce roles, depriving consumers of culturally responsive care; and poor work environments due to low pay, unmanageable workloads, and workplace stress—all of which lead providers to exit the field (Zhu et al., 2022).

The shortage of practitioners is not the only barrier to providing community services. Behavioral health staff may not be adequately trained, have the resources they need, or be able to find collaborative partners to handle the needs of people with serious mental disorders. There is also insufficient provision made for the other services people require to be able to access care: housing, food, and job training (Spielman et al., 2020).

Hardest hit by system failures are people who already have additional barriers to success, including people of color, immigrants, and sexual and gender minorities. These are populations that, even in the best of circumstances, are likely to face discrimination in accessing community services, housing, and education, and that have faced greater challenges post-deinstitutionalization in making their homes in the community (Deas-Nesmith & McLeod-Bryant, 1992). These marginalized and underserved groups are at significant risk of becoming homeless and justice-involved (Spielman et al., 2020).

Links to Homelessness and Incarceration

Some observers, noting the current housing crisis, as well as overflowing jails and prisons, are quick to blame deinstitutionalization for these problems. Indeed, a large portion of the unhoused population has one or more mental disorders. An estimated 20% to 30% of unhoused individuals have a serious mental illness such as schizophrenia (figure 1.19), and a startling 50% are thought to have traumatic brain injuries—far beyond the numbers found in the general population (Padgett, 2020). Likewise, jails and prisons began to fill to critical levels around the same time state hospitals were emptying, and correctional facilities are now the largest providers of mental health services in America.

Other observers point out that deinstitutionalization did not cause homelessness, nor did it deprive people of treatment in their communities. Rather, the initial wrong that had to be righted was institutionalization. Then, shortages of care, housing, and other services followed and failed to be addressed. Additionally, stigma surrounding people with mental disorders contributes to the marginalization of this population. Stigma refers to persistent and unfounded negative attitudes aimed at categories of people, and it is a foundation for prejudice and discrimination. It is harder for people who experience mental disorders to find housing, get jobs, and otherwise succeed in the face of these barriers. Denial of opportunities based on a person’s disability status may be illegal, but it is common and persistent (Ponte, 2020).

The deinstitutionalization movement also did not require the growth of jails and prisons. In fact, the “war on drugs” of the 1970s and 1980s and the “get tough on crime” movements of the 1980s and 1990s are more direct causes of mass incarceration in America. The supposed shift of people directly from state hospitals into jails and prisons is sometimes referred to as transinstitutionalization, a hypothesis suggesting that the same group of people simply moved from one institution (hospitals) to another (prisons). However, while people with mental disorders are indeed disproportionately found in jails and prisons, this is for many reasons that go beyond the simple assumption that people with mental disorders simply had to be moved from one institution to another (Prins, 2011).

For example, aside from reasons for increased initial incarceration, there is the significant factor of continued or repeated incarceration. Studies indicate that people with mental disorders get “stuck” in jail and prison significantly longer than other people: they are denied pretrial release more frequently, and they receive longer sentences more often. Additionally, once in prison, people with mental disorders are often not provided with adequate or effective treatment, leading them to incur new charges or fail to qualify for parole, which keeps them in prison. Alternately, if released untreated, people with mental disorders are less likely to succeed upon release; they are at high risk of reoffending and cycling back into the criminal justice system (Ponte, 2020).

There is also strong evidence that simply putting more people into psychiatric hospitals—a re-institutionalization of sorts—would be a very expensive and otherwise problematic reaction that would not significantly decrease the number of people with mental disorders in the criminal justice system. Rather, solutions like providing housing and other community support are far more effective in preventing criminal system involvement (Prins, 2011).

Licenses and Attributions for Mental Disorders Post-Deinstitutionalization

Open Content, Original

“Mental Disorders Post-Deinstitutionalization” by Anne Nichol is licensed under CC BY 4.0.

Open Content, Shared Previously

Figure 1.19. “Unmet Behavioral Health Needs” by The Bureau of Justice Assistance is in the public domain.