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DEINSTITUTIONALIZATION
Sociologyindex, Sociology Books 2009
Deinstitutionalization is reduction in the size of populations
held in institutions of involuntary confinement, primarily mental hospitals and prisons.
Deinstitutionalization movement began in the 1970s and was very
successful in reducing the size of mental hospitals.
While prison populations appeared to decrease in the United
States for a short time, there was a subsequent increase of unprecedented dimension.
Community mental health programs and community corrections
developed in response to the desire for deinstitutionalization, but community corrections
has come to be seen as an aspect of net widening.
Some Perspectives on Deinstitutionalization
H. Richard Lamb, M.D. and Leona L. Bachrach, Ph.D.
The authors discuss what can be learned from our experience with deinstitutionalization.
The deinstitutionalization of mentally ill persons has three components: the release of
these individuals from hospitals into the community, their diversion from hospital
admission, and the development of alternative community services. The greatest problems
have been in creating adequate and accessible community resources. Where community
services have been available and comprehensive, most persons with severe mental illness
have significantly benefited. On the other hand, there have been unintended consequences
of deinstitutionalization—a new generation of uninstitutionalized persons who have
severe mental illness, who are homeless, or who have been criminalized and who present
significant challenges to service systems. Among the lessons learned from
deinstitutionalization are that successful deinstitutionalization involves more than
simply changing the locus of care; that service planning must be tailored to the needs of
each individual; that hospital care must be available for those who need it; that services
must be culturally relevant; that severely mentally ill persons must be involved in their
service planning; that service systems must not be restricted by preconceived ideology;
and that continuity of care must be achieved. - psychservices.psychiatryonline.org/cgi/
content/abstract/52/8/1039
Radical deinstitutionalization: Rousseau versus
Freud
Author: Mayerhoff, David
Abstract: Background & aims: This paper considers the policy of radical
deinstitutionalization of the chronic, treatment-refractory mentally ill from the
perspective of two theories concerning the nature of man and civilization.
Method: Two apparently opposing points of view are reviewed, that of J. J. Rousseau and
that of S. Freud. Results & conclusions: An extrapolation from these points of view
suggests that neither would espouse a categorical view of deinstitutionalization in the
context of current societal conditions. - ingentaconnect.com
The Satellite System: A Model for Deinstitutionalization.
Authors: Boyan, Craig
Abstract: The paper presents the community-based satellite system as a residential and
program model to effect deinstitutionalization of mentally retarded young adults in urban
centers worldwide. The system is reported to consist of a large, central educational
facility surrounded by a series of small houses and apartment units (satellites). Benefits
of this environment are discussed: small, family-style houses with a concentration of
qualified support staff; easy development of continua of instruction between various
satellite facilities; opportunity to teach basic skills in environments where they are
normally learned; and no necessity for new construction costs. The author suggests that,
with adaptations, the satellite model is applicable throughout the world in urban, and
possibly rural, environments. - eric.ed.gov
Testing the limits of deinstitutionalization
RL Okin
San Francisco General Hospital, California 94110, USA.
OBJECTIVE: From 1978 to 1993, under favorable administrative and political conditions and
protected by a court-ordered consent decree, a comprehensive community-based mental health
system was established in western Massachusetts that entirely replaced Northampton State
Hospital. This paper examines that experience to describe the characteristics and
comparative department of mental health expenditures on alternative treatment settings and
to explore whether the need for state hospitals can be eliminated. METHODS: Data on
distribution and department of mental health funding of services in western Massachusetts
were compared with similar data from the rest of the state, where state hospital
utilization remained relatively high. RESULTS: Between 1978 and 1992, department of mental
health expenditures on noninpatient community services in western Massachusetts increased
from 15 percent to 74 percent of total expenditures on adult mental health services. In
1992 per capita expenditures on such services in western Massachusetts and the rest of the
state were similar. However, per capita expenditures for inpatient services constituted 27
percent of total expenditures in western Massachusetts, compared with 53 percent in the
rest of the state. Western Massachusetts spent approximately twice as much per capita on
residential and emergency services and one and a half times as much on case management
services and support. Very few Northampton patients were transferred to nursing homes, and
the inpatient census per 100,000 population supported by the department of mental health
in western Massachusetts was one-third of that in the rest of the state. CONCLUSION: Under
certain conditions, the role and functions of state hospitals can be completely replaced
by a system of comprehensive community services. - psychservices.psychiatryonline.org/cgi/
content/abstract/46/6/569
Deinstitutionalization, another way: The Italian mental health reform
OTA DE LEONARDIS, Associate Professor of Sociology, DIANA MAURI, CNR Project
Research Fellow and FRANCO ROTELLI, Director
University of Salerno Department of Sociology, University of Milan Mental Health Services
Trieste The article describes the Italian experience of deinstitutionalization in
psychiatry, a reform which has attracted international recognition as being the only
instance of an industrial society eliminating detention in a mental hospital from its
range of mental health agencies and services.
The first part of the article highlights the differences between the Italian experience
and psychiatric reforms in Europe and the US, where deinstitutionalization has been
reduced to dehospitalization. The problems and failings of these reforms are
examined.
The second part describes the operation, very different in content and method from the
above quoted experiences, of the Italian form of deinstitutionalization. Starting from a
critique of the rationalistic problem-solution "paradigm" in psychiatry, it has
developed as a complex social process which: a)involves all its subjects as active
participants, b) transforms the power relationship existing between the patient (and
citizen) and the institution, c) creates mental health services which completely replace
detention in mental hospitals by deconstructing them and reconverting the material and
human resources found in them.
An example of this reconversion is given in the way in which mental health services have
been organized in Trieste.
The fourth part examines the reform law arising from the deinstitutionalization process
and the characteristics of its implementation, in order to show how this process continues
through implementation.
In the light of these considerations, deinstitutionalization is no longer perceived as an
aspect of the "welfare crisis", but rather as a significant pointer to new
post-welfare social policies. - heapro.oxfordjournals.org/cgi/ content/abstract/1/2/151
Criminal Offending in Schizophrenia Over a 25-Year Period Marked by
Deinstitutionalization and Increasing Prevalence of Comorbid Substance Use Disorders
Cameron Wallace, Ph.D., Paul E. Mullen, M.B.B.S., D.Sc., F.R.A.N.Z.C.P.,
F.R.C.Psych. and Philip Burgess, Ph.D.
OBJECTIVE: This study examined the pattern of criminal convictions in persons with
schizophrenia over a 25-year period marked by both radical deinstitutionalization and
increasing rates of substance abuse problems among persons with schizophrenia in the
community. METHOD: The criminal records of 2,861 patients (1,689 of whom were male) who
had a first admission for schizophrenia in the Australian state of Victoria in 1975, 1980,
1985, 1990, and 1995 were compared for the period from 1975 to 2000 with those of an equal
number of community comparison subjects matched for age, gender, and neighborhood of
residence. RESULTS: Relative to the comparison subjects, the patients with schizophrenia
accumulated a greater total number of criminal convictions (8,791 versus 1,119) and were
significantly more likely to have been convicted of a criminal offense (21.6% versus 7.8%)
and of an offense involving violence (8.2% versus 1.8%). The proportion of patients who
had a conviction increased from 14.8% of the 1975 cohort to 25.0% of the 1995 cohort, but
a proportionately similar increase from 5.1% to 9.6% occurred among the comparison
subjects. Rates of known substance abuse problems among the schizophrenia patients
increased from 8.3% in 1975 to 26.1% in 1995. Significantly higher rates of criminal
conviction were found for patients with substances abuse problems than for those without
substance abuse problems (68.1% versus 11.7%). CONCLUSIONS: A significant association was
demonstrated between having schizophrenia and a higher rate of criminal convictions,
particularly for violent offenses. However, the rate of increase in the frequency of
convictions over the 25-year study period was similar among schizophrenia patients and
comparison subjects, despite a change from predominantly institutional to community care
and a dramatic escalation in the frequency of substance abuse problems among persons with
schizophrenia. The results do not support theories that attempt to explain the mediation
of offending behaviors in schizophrenia by single factors, such as substance abuse, active
symptoms, or characteristics of systems of care, but suggest that offending reflects a
range of factors that are operative before, during, and after periods of active illness. -
ajp.psychiatryonline.org/cgi/ content/abstract/161/4/716
Deinstitutionalization of psychiatric patients, a critical review of outcome
studies
P Braun, G Kochansky, R Shapiro, S Greenberg, JE Gudeman, S Johnson and MF
Shore
The authors performed a critical review of experimental studies on the outcomes for
psychiatric patients of 1) alternatives to hospital admission, 2) modifications of
conventional hospitalization, and 3) alternatives to continued long-term hospitalization.
The internal validity of many of the studies was compromised by shortcomings in design and
performance and generalizability limited by selection of patient populations. With these
qualifications experimental alternatives to hospital care of patients have led to
psychiatric outcomes not different from and occasionally superior to those of patients in
control groups. This conclusion is best supported for alternatives to admission and for
modifications of conventional hospitalization. The available studies do not permit firm
conclusions regarding alternatives to continued long-term hospitalization of chronically
ill patients or for a critical analysis of the optimal management of specific
subpopulations of psychiatric patients. Satisfactory deinstitutionalization appears to
depend on the availability of appropriate programs for care in the community. -
ajp.psychiatryonline.org/cgi/ content/abstract/138/6/736
Deinstitutionalization of Status Offenders: Individual Outcome and System
Effects
Irving A. Spergel, Frederic G. Reamer, James P. Lynch
In recent years there have been widespread attempts to remove juvenile status offenders
from secure detention and correctional facilities. These efforts have been in response to
claims that status offenders do not represent a significant danger to the community and
that incarceration of them is unwarranted. This article summarizes findings from the
evaluation of a statewide program, designed as part of a national deinstitutionalization
strategy, that provided alternatives to secure detention for status offenders between the
time of arrest and court appearance. It focuses on factors affecting both the youths
themselves and the responses of the juvenile justice and public social service systems to
the alternatives program. In particular, the effects of secure detention and alternatives
to detention on youths' subsequent behavior are compared. In addition, data are provided
concerning status offenders' careers and the ability of the deinstitutionalization
strategy to divert youths from the juvenile justice and social service systems. -
jrc.sagepub.com/cgi/ content/abstract/18/1/4
Deinstitutionalization and the ‘long-term mentally ill’: a Swedish case
study
ERIK FORSBERG and BENGT STARRIN
Centre for Public Health Research, The County Council of Värmland Karlstad, Sweden
Corropondence: Erik Forsberg, Centre for Public Health Research, The County Council of
Värmland, S-652 82 Karlstad, Sweden
We discuss deinstitutionalization and the question of how ‘long-term mentally
ill’ persons adjust to life outside institutions. An interview survey was conducted
in 1990 with 61 persons who had been discharged to the community from a mental hospital in
the County of Värmland, Sweden during the 1980s after at least five years inpatient care.
The question of accommodation was solved for all the interviewees prior to discharge and
all now live in modern apartments. Each discharge was preceded by an individual plan. The
majority of the 61 ex-patients still had contact with psychiatry in some form but only 19
had been treated in inpatient psychiatric care since they were discharged. While the
ex-patients' material standard of living was satisfactory, the situation with respect to
the occupation and fellowship was not. The need for intermediate forms of individually
adapted occupation and supportive housing conditions is discussed. -
eurpub.oxfordjournals.org/cgi/ content/abstract/3/2/137
The Leros PIKPA Asylum Deinstitutionalization and Rehabilitation Project
A follow-up study on care staff fears and attitudes
John Tsiantis, Department of Child Psychiatry, Athens University Medical School,
Greece
Stavroula P. Diareme, Department of Child Psychiatry, Athens University Medical School,
Greece
Gerasimos Kolaitis, Department of Child Psychiatry, Athens University Medical School,
Greece
This is a three-year follow-up study on the results from the Deinstitutionalization
Project of the Leros PIKPA asylum regarding job-related fears of care staff of the
institution as well as their attitudes towards people with learning disabilities. We
expected that changes in staff would occur in a way congruent with previously published
findings indicating that after a year of intervention staff became less worried about
residents’ aggression and their own personal health, and understood better
residents’ individual differences and need for non-custodial care. Care staff of the
institution responded to a number of ‘fear statements’, and to an attitude
questionnaire after a three-year intervention including several forms of training, support
and sensitivity groups. Qualitative observations of staff behaviour were also examined.
Data analyses showed that staff fears of expression of aggression in the institution
decreased, whereas fears regarding their own aggression increased. Staff worries about
their personal health decreased progressively from baseline assessment. Comparisons in
staff attitudes indicated that staff continued to move away from the idea of custodial
segregation of people with learning disabilities. Observational data showed improvements
in staff management practices and interactions with residents. Results are discussed
within the frame of particular Greek socio-cultural factors. -
jid.sagepub.com/cgi/content/abstract/4/4/281
Race and the Impact of Juvenile Deinstitutionalization
M. A. Bortner, Mary L. Sunderland, Russ Winn
In a study of 32,000 referrals to juvenile court, the effects of a program to
deinstitutionalize status offenders on detention decisions, intake screening, and final
dispositions were examined. Although the results of a general comparison of preprogram and
postprogram court actions showed relatively little change in court policies, the data did
indicate a slight general trend toward less use of secure detention, a greater use of
informal hearings, and a lower rate of juveniles placed on probation or in institutions.
Differential treatment based on race was evident throughout the 5-year period. Whereas the
rate of secure detention of black juveniles declined overall, it increased for black
status offenders, especially females. There was a substantial decrease in the use of
formal hearings and in the severity of final dispositions for all cases involving black
juveniles. - cad.sagepub.com/cgi/content/abstract/31/1/35
Deinstitutionalization's Throwaways: The Development of a Juvenile Prison in
Massachusetts
Ronald E. Vogel
Edward A. Thibault
With its deinstitutionalization of juvenile offenders in the early 1970s, the Department
of Youth Services in the state of Massachusetts de veloped the reputation of being
extremely progressive. However, the label progressive does not characterize all forms of
juvenile correction under the new system. In the midst of deinstitutionalization, a small
maximum-security prison was developed for juvenile offenders who could not be treated in
any of the community-based programs de signed to replace the training schools. Despite all
the therapeutic jargon and liberal claims relating to secure care, the Worcester Secure
Treatment Program was and remains a prison. Attempts to impose concepts of treatment in
this maximum-security, custodial setting have led to conflict and confusion in objectives,
with unfortunate re sults. - cad.sagepub.com/cgi/content/abstract/27/4/468
Deinstitutionalization for Older Adults With Severe Mental Retardation: Results
From Australia
Louise Young and Adrian F. Ashman
University of Queensland, Fred and Eleanor Schonell Special Education Research Center
Abstract: A deinstitutionalization research project in which residents from the largest
institution in Queensland, Australia, were relocated after a government decision to close
the center was described. Outcomes of relocation into community living for adults with
severe mental retardation, many of whom were older (over 40 years) and had been
institutionalized for much of their lives, was addressed within the Australian context.
Results from the relocation and outcomes for people aged 20 to 39 years (n = 37), 40 to 59
years (n = 39), and over 60 years (n = 24) were described. Group results focused on
adaptive and maladaptive behavior, choice-making, and objective life quality were
discussed together with the implications for service provision. - aamr.allenpress.com
Longitudinal Study of Deinstitutionalization and the Exercise of Choice
Roger J. Stancliffe, and Brian H. Abery
Abstract: Day-to-day choices available to former institution residents with
severe/profound developmental disabilities (movers) were assessed before and after
deinstitutionalization and compared with peers who remained in the same institutions
(stayers). Data were gathered annually for both groups for 3 years after baseline.
Personal characteristics of the two groups did not differ significantly at baseline,
except that stayers exhibited more challenging behavior. This was controlled by using
baseline challenging behavior as a covariate in group comparisons. Overall, movers
exercised significantly more choice, although groups did not differ at baseline. Effects
of deinstitutionalization did not differ with level of disability. However, the absolute
level of choice available to both movers and stayers was very low. - aamr.allenpress.com
Deinstitutionalization of Minors with Mental Retardation. Abstract X: Research
& Resources on Special Education.
Abstract: The brief paper summarizes the final report of a federally funded
project titled, "Ramps Are Not Enough: The Movement of Children with Mental
Retardation from Institutional to Community-Based Care." The follow-up study of
former residents (N=178) of New Hampshire's Laconia State School included an examination
of residential and educational consequences of deinstitutionalization, four in-depth case
studies, and an effort to trace the chronological relationship between federal and state
policy and budgetary changes and the community living experiences of subjects. Among
results were the following: on leaving the school, most residents returned to natural
families, foster, or group homes; although ex-residents tended to stay in community
placements an average of 3 to 4 years, almost half of the placements lasted less than 1
year and almost one-third of the subjects returned to the state school; although most
children were originally placed in self-contained classrooms or schools many were later
changed to less restrictive placements; about one-half of the sample changed educational
placements once; vocational special education was received by relatively few children; and
training in daily living skills or self-help skills was provided to most of the sample. -
eric.ed.gov
Deinstitutionalization has been reduced to dehospitalization
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