The Implementation of Deinstitutionalization
The deinstitutionalization of mental hospitals created a large shift in the trajectory of where mental healthcare was going. Authors Ellen L. Bassuk and Samuel Gerson, Gary J. Clarke, Alexander Gralnick, Stephen M. Rose, and David A. Rochefort and David Mechanic all provide different answers to one frequently arising question about deinstitutionalization; why was it implemented? Mental health hospitals evolved over time until deinstitutionalization began, but historians think differently about why exactly it was implemented. Some historians argue that deinstitutionalization was implemented due to lack of funds, politics, or ethics, but the most compelling argument is the government’s willingness to act only when funds become involved.
From exorcisms to psychiatric drugs, mental healthcare has come a long way. As religion became more and more separate from the state around 1800, mental illness was seen less as demonic possession and more as a moral weakness (Bassuk & Gerson, 46). Before mental health hospitals became popularized, families were expected to treat their mentally or physically sick family members at home by implementing isolation. But as this went on, more of the people who struggled with mental health and were staying in their homes became violent and aggressive due to improperly treated mental illness. The first mental health hospital started in 1811 outside of Boston, Massachusetts and housed 13 patients in the first three months (McLean Hospital). The movement slowly started to grow and in 1890 every state in the US had built one or more public mental health hospitals (National Library of Medicine). Called insane asylums at the time, a lack of understanding surrounding mental health turned these establishments from a hope for healing into an incredibly hostile and dehumanizing environment. Patients were treated harshly with little to no empathy shown towards them. As more information surrounding the treatment in mental health centers came to surface, people began to criticize the industry. This led to the idea of deinstitutionalization. Deinstitutionalization was the movement from 1956-1975 to move people from privately or publicly owned mental facilities back with their families or into community run mental facilities.
Stephen M. Rose argues that economic issues and lack of funds were the main reasons why deinstitutionalization was implemented. Rose wrote Deciphering Deinstitutionalization: Complexities in Policy and Program Analysis and through this essay, he shares a list of reasons why deinstitutionalization was implemented, each reason leading back to funds, or the lack thereof. Mental health hospitals already had a low budget and caring for patients was expensive. According to Rose, “the annual average cost of caring for [one] person in a public mental hospital in 1974 was $11,250” (Rose, 446). On top of this, the SSI, the Supplemental Security Income program, provided money to mental hospitals so they could continue running. But the total amount of money that the SSI gave to mental hospitals barely scratched the surface of what was needed to support patients. Simply put, mental hospitals were slowly losing more and more money. Moving patients from mental hospitals into state facilities or back home was a way for the mental hospitals of the time to save money. Rose sums it up perfectly, writing that “medical determination of the best methods of treatment has consistently been regulated by the economic needs of the state” (Rose, 454). This argument is strong because Rose’s idea that funds were the leading factor of the implementation of deinstitutionalization aligns with the history of the United States and its focus on economics and economic values. Throughout history, money has run the country. It has been the reason for many important choices that have changed the trajectory of American history, like the Great Depression and the Louisiana Purchase. Following this, money would be a big factor in determining the future of mental hospitals. Without proper funding, there would be no hope for patients with mental illness to get better.
Gary J. Clarke sees the reasons for the implementation of deinstitutionalization as merely political, yet his argument lacks substantial analysis in this idea. Although lack of funding is widely agreed upon to be a reason for deinstitutionalization, Gary J. Clarke, author of In Defense of Deinstitutionalization, disagrees with the commonly perceived impact that lack of funding had. Clarke recognizes that funds were a reason for deinstitutionalization, but sees that there were more factors at play than just that. Clarke’s argument is not strong though, as he only includes one other reason for the possible cause of why deinstitutionalization was implemented in the first place. He says that it was attractive to both liberals and conservative politicians because liberals wanted to free mental patients from inhumane institutions, and conservatives wanted to save money (Clarke, 468). Because both groups had reasons to support the movement, it was easier to agree on the idea that deinstitutionalization would be beneficial for society. This argument is not strong because Clarke’s reasoning allowed the transition into deinstitutionalization to be easier, but it did not cause the implementation. Political agreement does not push a movement into creation. It only helps said movement become implemented, but it does not cause the implementation. When comparing this argument to Rose’s, one can see that Rose’s argument on the importance of money is more compelling than Clarke’s. Rose offers a direct reason for the cause of deinstitutionalization while Clarke does not. Clarke does not consider any possible reasons why deinstitutionalization was implemented, he simply provides one reason that only helped the transition into deinstitutionalization.
Alexander Gralnick, Ellen L. Bassuk and Samuel Gerson, and David A. Rochefort and David Mechanic all think that ethics were the main reason why deinstitutionalization was implemented, yet they all had different reasons as to why they believed this. Alexander Gralnick wrote Is There a Continuing Role for the Mental Hospital?: A Personal View. He saw deinstitutionalization as the government’s way to get patients out of the horrific conditions in state mental hospitals, which were, “…something akin to jails and almshouses, where patients could only be ‘stored’” (Gralnick, 4). As well as addressing the influences of funding, Gralnick notes that people thought hospitalization caused chronicity and if people stayed in the community instead of a state hospital, their condition would not be as chronic (Gralnick, 7). This belief, as well as people recognizing the inhumane conditions in mental hospitals, caused the push for deinstitutionalization. Ellen L. Bassuk and Samuel Gerson’s Deinstitutionalization and Mental Health Services argues that the reformers of deinstitutionalization had an unrealistic and overly optimistic outlook towards the movement. At the time, mental illness was thought to be “fixable.” Families, nurses, and reformers all gained hope and optimism about the future of mental healthcare from this thought. Due to the supposed possibility to “fix” people with mental illness, people were eager to find solutions to treat it. Reformers often looked at the movement through rose-colored glasses without stopping to consider any negative results. Similarly, David A. Rochefort and David Mechanic wrote in Deinstitutionalization: An Appraisal of Reform that the time period of the 1960s and 1970s was a time of expansion of social welfare and ethical views. Due to this shift in thinking, deinstitutionalization was more widely received and directly impacted the implementation since more people saw how unethical the mental hospitals of the time were. Rochefort and Mechanic say that during this time, the government began to protect the health and well-being of its citizens more, which in turn reinforced the belief that all people are equal and showed the importance of ethical leadership (Rochefort & Mechanic, 304). This change in thought in the 60s and 70s created a more conducive environment to implement deinstitutionalization due to people’s changed mindsets and broader ethics. Each of these historians communicate a strong argument. Ethics and how people see morality are issues that arise through conversations about mental hospitals. Ethics are the most important factor to create change because without an idea of what is right vs. wrong, people would not take action to change the things they see as immoral. Gralnick, Bassuk and Gerson, and Rochefort and Mechanic all present compelling arguments surrounding the idea of ethical care. Compared to the previous authors, ethics is a reason for the transition as well as the implementation into deinstitutionalization. Seeing something that needs to be changed can create a sense of purpose and drive to help. This is important because without an ethical outlook on mental hospitals, deinstitutionalization would have never been implemented.
Lack of care for people with mental illness is shown through each historian’s reasoning for why deinstitutionalization was implemented. Interestingly enough, none of these historians think the main reason that deinstitutionalization was implemented was due to the government wanting to support people with mental illness. Even though there was a large group that saw the reasoning as relating to ethics, none of the historians wrote that the government wanted to actively help people who were struggling with mental illness. Bassuk and Gerson say that people wanted to “fix” mental illness, Gralnick says that the government wanted to move people out of mental hospitals, and Rochefort and Mechanic say that there were changing ethics during the 60s and 70s. But all of these reasons show no real drive from the government to fully support people with mental illness. Wanting to “fix” people who had a mental illness shows that the government only wanted people who fit inside their standards of a functioning society, as they were unwilling to try to understand people with mental illness or accommodate them. And Gralnick’s argument of wanting to move people out of mental hospitals may just have been because of the complaints that people were bringing up surrounding the conditions of these institutions. Further supporting this, Rochefort and Mechanic’s argument has to do with a change in thinking, not a change in the government’s outlook of people with mental illness. These historians could agree that the government did not take moves to fully understand people with mental illness. The most compelling and believable argument is Rose’s because the government was eager to fix things once money and funds became involved. Throughout history, the government has sided with the money instead of the people, and deinstitutionalization is no exception.
Some historians argue that the implementation of deinstitutionalization was due to funds, politics, or ethics, but the real reason for the implementation was the government’s lack of involvement until funds became a concern. These five historians all have different views on why deinstitutionalization was implemented. Rose’s argument about the lack of funds that led to the implementation of deinstitutionalization provides one view on this idea. From Clarke’s insufficient reasoning to Gralnick, Bassuk, Gerson, Rochefort, and Mechanic’s argument about ethics, there are many different ways to view why deinstitutionalization was implemented.
Ayla Bernardo
Mr. Sheldon
Advanced US History
13 March, 2025
Works Cited
Bassuk, Ellen L., and Samuel Gerson. “Deinstitutionalization and Mental Health Services.” Scientific American, vol. 238, Feb. 1978, pp. 1-8. JSTOR, www.jstor.org/stable/24955635. Accessed 9 Feb. 2025.
This magazine article from 1978 argues that deinstitutionalization prioritized protecting society over providing helpful mental healthcare for individuals. Hospitals were only deinstitutionalized because it was thought that deinstitutionalization would create more profits. The authors write, “does ‘deinstitutionalization’ represent an enlightened revolution or an absence of responsibility” (Bassuk, Gerson)? After deinstitutionalization, if someone needed to be in a mental health facility, they were often placed in a nursing home. This created crowded hospitals where patients would stay longer than needed due to inadequate care. After being readmitted back into society, people with mental illness were not provided with affordable healthcare or, in some cases, any follow-up care. Facilities also did not have the funds or resources to broaden their knowledge and advance mental healthcare. Many factors contributed to the failure of deinstitutionalization, but Bassuk and Gerson argue that because hospitals were only deinstitutionalized because it would create more profits, deinstitutionalization was never set up to truly help the patients.
Clarke, Gary J. “In Defense of Deinstitutionalization.” JSTOR, Sept. 1979, www.jstor.org/stable/3349722. Accessed 9 Feb. 2025.
This piece from 1979 argues that deinstitutionalization is largely misunderstood. Clarke makes sure to define deinstitutionalization as “moving patients out of hospitals,” not “putting patients into community care” like many think, even though that often was the case. This work argues that deinstitutionalization, although failed, was a better alternative than the previous mental health system and abusive hospitals. Clarke also notes that the failure of deinstitutionalization was not due to only lack of funds, as many historians say. It was a new and experimental attempt to provide more humane care to people with mental illness, but did not end up working due to a multitude of reasons.
Gralnick, Alexander. “Is There a Continuing Role for the Mental Hospital?: A Personal View.” JSTOR, Dec. 1989. Accessed 9 Feb. 2025.
Written in 1989, Gralnick describes the detrimental effects of deinstitutionalization. He writes how people who struggle with mental illness are treated with much less compassion and respect than people who struggle with physical illness. After deinstitutionalization, it was unclear who was responsible for taking care of people with mental illness. Was it the federal government? State government? Town government? Something else completely? Gralnick writes that “Deinstitutionalization sidetracked the logical evolution of the public hospital system and destroyed its potential as a seat of learning, education, and research” (Gralnick). The overall failure of deinstitutionalization proved to be tragic and difficult to come back from.
McLean Hospital. “History and Progress.” McLean Hospital, www.mcleanhospital.org/about/history-progress#:~:text=The%20Asylum%20opened%2C%20a%20division,months%20McLean%20admitted%2013%20patients. Accessed 12 Mar. 2025.
This was used to find information about one of the first mental hospitals.
Mechanic, David, and David A. Rochefort. “Deinstitutionalization: An Appraisal of Reform.” JSTOR, 1990, www.jstor.org/stable/2083272. Accessed 9 Feb. 2025.
This piece written in 1990, goes over how the already problematic mental healthcare system only became more problematic through deinstitutionalization. Many things, like deinstitutionalization, were put into place to help people with mental illness, yet they only made things worse. Patients who were discharged from mental hospitals were meant to be provided with follow-up care, but the inadequate planning and execution of the aftermath of deinstitutionalization predetermined its downfall. People were not provided with the important, life-saving care that they needed.
National Library of Medicine. “Timeline of Early Psychiatric Hospitals and Asylums.” National Library of Medicine, www.nlm.nih.gov/hmd/topics/diseases-of-mind/timeline.html. Accessed 12 Mar. 2025.
Provided information about early mental hospitals.
Rose, Stephen M. “Deciphering Deinstitutionalization: Complexities in Policy and Program Analysis.” JSTOR, 1979, www.jstor.org/stable/3349721. Accessed 9 Feb. 2025.
This work was written in 1979 and brings up important questions about deinstitutionalization. Rose wonders why, at the time of the piece, policies of deinstitutionalization were still growing while other social reforms and movements were declining or had died. He also brings up questions like what is the extent of social acceptance of mental illness? He recognizes the successes and failures of deinstitutionalization, like how it “has failed substantially in preventing mental breakdown or hospitalization, while at the same time tremendous progress has been made in reducing the overall number of inpatient beds in state hospitals” (Rose). Overall, Rose creates important questions about the morality of mental hospitals and deinstitutionalization as a whole.
