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Social justice
29 July 2013

The twisted roots of ‘care in the community’

The Americans call it “deinstitutionalization” – an uglier, if less euphemistic, name for what we call ‘care in the community’. Though now regarded by many as a disaster, there was, at the time, broad support for closing down the old asylums – which were seen as places of horror.

However, as James Panero explains in an article for City Journal, they did not start out that way – they were built by 19th century social reformers as places of genuine care for the mentally ill. It was only later that things went downhill:

  • “...in the twentieth century, a shadow fell over the asylums, as doctors there began using more invasive procedures. The Austrian psychiatrist Manfred Sakel introduced insulin shock therapy, now known as insulin coma therapy, in the 1930s. Electroshock therapy arrived from Italy soon after. Both treatments induced seizures to alter brain chemistry in patients with depression and schizophrenia.”

Worst of all were various forms of lobotomy, including the horrific practice of transorbital lobotomy as developed by the physician Walter J Freeman II:

  • “Freeman performed the ten-minute operation—in which he inserted long metal rods around the eyeballs of his patients and penetrated, stirred, and severed their frontal brain matter—some 3,500 times.”

Among Freeman's patients – or victims, rather – was a  23-year-old woman called Rosemary Kennedy, who was left severely disabled by the procedure. Her tragedy would have wider consequences, because her brother John – who later became President of the United States – joined with his siblings in a “crusade against institutionalization”.

And yet, for all its good intentions, the deinstitutionalization movement failed to create an effective community-based care system for people with severe mental illnesses – who we continue to fail in both Britain and America:

  • “Within a year of leaving institutional care, according to researchers, half of all mentally ill patients fail to take their prescribed antipsychotic medications—a terrifying prospect for the vast numbers of patients who left the asylums under deinstitutionalization. Between 50 and 60 percent of patients discharged from state institutions were schizophrenic. Another 10 to 15 percent had been diagnosed with manic-depressive illness or severe depression.”

Panero notes that “over 90 percent of patients who would have been committed before deinstitutionalization are now out in the world.” Turned out of one kind of state institution (that was at least originally designed around their needs) many find themselves passing chaotically through other state institutions:

  • “Yes, expensive institutional beds have been eliminated. But weigh those savings against the costs that must be borne by other facilities, such as emergency rooms, prisons, jails, and nursing homes. ‘Untreated mentally ill individuals revolve endlessly through hospitals, courts, jails, social services, group homes, the streets and back again,’ reports the [Treatment Advocacy Center]. ‘It is a spectacularly inefficient and costly system, perhaps best symbolized by ‘Million Dollar Murray,’ a mentally ill homeless man who cost Nevada more than $1 million, mostly in emergency department costs, as he rotated through the system for 10 years’ Consider, too, the dollar burden that the mentally ill have piled on law enforcement agencies.”

Sadly, the American hopes expressed in the term ‘deinstitutionalization’ have proven to be every bit as ironic as the British vision of ‘care in the community.’


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