deinstitutionalisation deinstitutionalisation deinstitutionalisation (or deinstitutionalization) is the process of replacing long-stay psychiatric hospitals with less isolated community mental health services for those diagnosed with a mental disorder or developmental disability. in the late 20th century, it led to the closure of many psychiatric hospitals, as patients were increasingly cared for at home, in halfway houses and clinics, in regular hospitals, or not at all. the former st elizabeth's hospital in 2006, closed and boarded up. located in washington d.c., the hospital had been one of the sites of the rosenhan experiment in the 1970s. deinstitutionalisation works in two ways. the first focuses on reducing the population size of mental institutions by releasing patients, shortening stays, and reducing both admissions and readmission rates. the second focuses on reforming psychiatric care to reduce (or avoid encouraging) feelings of dependency, hopelessness and other behaviors that make it hard for patients to adjust to a life outside of care. the modern deinstitutionalisation movement was made possible by the discovery of psychiatric drugs in the mid-20th century, which could manage psychotic episodes and reduced the need for patients to be confined and restrained. another major impetus was a series of socio-political movements that campaigned for patient freedom. lastly, there were financial imperatives, with many governments also viewing it as a way to save costs. the movement to reduce institutionalisation was met with wide acceptance in western countries, though its effects have been the subject of many debates. critics of the policy include defenders of the previous policies as well as those who believe the reforms did not go far enough to provide freedom to patients. history 19th century vienna's narrenturm—german for "fools' tower"—was one of the earliest buildings specifically designed for mentally ill people. it was built in 1784. the 19th century saw a large expansion in the number and size of asylums in western industrialised countries. in contrast to the prison-like asylums of old, these were designed to be comfortable places where patients could live and be treated, in keeping with the movement towards "moral treatment". in spite of these ideals, they became overstretched, non-therapeutic, isolated in location, and neglectful of patients. 20th century by the beginning of the 20th century, increasing admissions had resulted in serious overcrowding, causing many problems for psychiatric institutions. funding was often cut, especially during periods of economic decline and wartime. asylums became notorious for poor living conditions, lack of hygiene, overcrowding, ill-treatment, and abuse of patients; many patients starved to death. the first community-based alternatives were suggested and tentatively implemented in the 1920s and 1930s, although asylum numbers continued to increase up to the 1950s. eugenics and aktion t4 the eugenics movement started in the late 19th century, but reached the height of its influence between the two world wars. one stated aim was to improve the health of the nation by ‘breeding out defects’, isolating people with disabilities and ensuring they could not procreate. charles darwin's son lobbied the british government to arrest people deemed as ‘unfit’, then segregate them in colonies or sterilise them. at the same time, in germany medics and lawyers joined forces to argue for the extermination of people with disabilities. the 1920 essay, “permitting the destruction of life unworthy of life” is seen by many as a blueprint for the nazis’ future crimes against humanity. in 1939, the nazi regime began ‘aktion t4’. through this programme, psychiatric institutions for children and adults with disabilities were transformed into killing centres. the government compelled midwives to report all babies born with disabilities, then coerced parents to place their children in institutions. visits were discouraged or forbidden. then medical personnel transformed a programme of institutionalisation into extermination. more than 5,000 children were killed in the network of institutions for children with disabilities, followed by more than 200,000 disabled adults. the medical and administrative teams who developed the first mass extermination programme were transferred – together with their killing technology – to set up and manage the deathcamps of treblinka and sobibor. the nazi crimes against people with mental illness and disabilities in institutions was one of the catalysts for moving away from an institutionalised approach to mental health and disability in the second half of the 20th century. origins of the modern movement the advent of chlorpromazine and other antipsychotic drugs in the 1950s and 1960s played an important role in permitting deinstitutionalisation, but it was not until social movements campaigned for reform in the 1960s that the movement gained momentum. a key text in the development of deinstitutionalisation was asylums: essays on the social situation of mental patients and other inmates, a 1961 book by sociologist erving goffman. the book is one of the first sociological examinations of the social situation of mental patients, the hospital. based on his participant observation field work, the book details goffman's theory of the "total institution" (principally in the example he gives, as the title of the book indicates, mental institutions) and the process by which it takes efforts to maintain predictable and regular behavior on the part of both "guard" and "captor", suggesting that many of the features of such institutions serve the ritual function of ensuring that both classes of people know their function and social role, in other words of "institutionalizing" them. franco basaglia, a leading italian psychiatrist who inspired and was the architect of the psychiatric reform in italy, also defined mental hospital as an oppressive, locked and total institution in which prison-like, punitive rules are applied, in order to gradually eliminate its own contents, and patients, doctors and nurses are all subjected (at different levels) to the same process of institutionalism. other critics went further and campaigned against all involuntary psychiatric treatment. in 1970, goffman worked with thomas szasz and george alexander to found the american association for the abolition of involuntary mental hospitalisation (aaaimh), who proposed abolishing all involuntary psychiatric intervention, particularly involuntary commitment, against individuals. the association provided legal help to psychiatric patients and published a journal, the abolitionist, until it was dissolved in 1980. reform the prevailing public arguments, time of onset, and pace of reforms varied by country. leon eisenberg lists three key factors that led to deinstitutionalisation gaining support. the first factor was a series of socio-political campaigns for the better treatment of patients. some of these were spurred on by institutional abuse scandals in the 1960s and 1970s, such as willowbrook state school in the united states and ely hospital in the united kingdom. the second factor was new psychiatric medications made it more feasible to release people into the community and the third factor was financial imperatives. there was an argument that community services would be cheaper. mental health professionals, public officials, families, advocacy groups, public citizens, and unions held differing views on deinstitutionalisation. however, the 20th century marked the development of the first community services designed specifically to divert deinstitutionalization and to develop the first conversions from institutional, governmental systems to community majority systems (governmental-ngo-for profit). these services are so common throughout the world (e.g., individual and family support services, groups homes, community and supportive living, foster care and personal care homes, community residences, community mental health offices, supported housing) that they are often "delinked" from the term deinstitutionalization. common historical figures in deinstitutionalization in the us include geraldo rivera, robert williams, burton blatt, gunnar dybwad, michael kennedy, frank laski, steven j. taylor, douglas p. biklen, david braddock, robert bogdan and k. c. lakin. in the fields of "intellectual disabilities" (e.g., amicus curae, arc-us to the us supreme court; us state consent decrees). community organizing and development regarding the fields of mental health, traumatic brain injury, aging (nursing facilities) and children's institutions/private residential schools represent other forms of diversion and "community re-entry". paul carling's book, return to the community: building support systems for people with psychiatric disabilities describes mental health planning and services in that regard, including for addressing the health and personal effects of "long term institutionalization". and the psychiatric field continued to research whether "hospitals" (e.g., forced involuntary care in a state institution; voluntary, private admissions) or community living was better. us states have made substantial investments in the community, and similar to canada, shifted some but not all institutional funds to the community sectors as deinstitutionalization. for example, nys education, health and social services laws identify mental health personnel in the state of new york, and the two term obama presidency in the us created a high-level office of social and behavioral services. the 20th century marked the growth in a class of deinstitutionalization and community researchers in the us and world, including a class of university women. these women follow university education on social control and the myths of deinstitutionalization, including common forms of transinstitutionalization such as transfers to prison systems in the 21st century, "budget realignments", and the new subterfuge of community data reporting. consequences community services that developed include supportive housing with full or partial supervision and specialised teams (such as assertive community treatment and early intervention teams). costs have been reported as generally equivalent to inpatient hospitalisation, even lower in some cases (depending on how well or poorly funded the community alternatives are). although deinstitutionalisation has been positive for the majority of patients, it also has shortcomings. walid fakhoury and stefan priebe suggest that modern day society now faces a new problem of "reinstitutionalisation". and many critics argue that the policy left patients homeless or in prison. leon eisenberg has argued that deinstitutionalisation was generally positive for patients, while noting that some were left homeless or without care. medication there was an increase in prescriptions of psychiatric medication in the years following deinstitutionalization. although most of these drugs had been discovered in the years before, deinstitutionalisation made it far cheaper to care for a mental health patient and increased the profitability of the drugs. some researchers argue that this created economic incentives to increase the frequency of psychiatric diagnosis (and related diagnoses, such as adhd in children) that did not happen in the era of costly hospitalized psychiatry. in most countries (except some countries that are either in extreme poverty or are hindered from importing psychiatric drugs by their customs regulations), more than 10% of the population are now on some form of psychiatric medicine. this increases to more than 15% in some countries such as the united kingdom. a 2012 study by kales, pierce and greenblatt argued that these medicines were being overprescribed. victimisation moves to community living and services have led to various concerns and fears, from both the individuals themselves and other members of the community. over a quarter of individuals accessing community mental health services in a us inner-city area are victims of at least one violent crime per year, a proportion eleven times higher than the inner-city average. the elevated victim rate holds for every category of crime, including rape/sexual assault, other violent assaults, and personal and property theft. victimisation rates are similar to those with developmental disabilities. misconceptions there is a common perception by the public and media that people with mental disorders are more likely to be dangerous and violent if released into the community. however, a large 1998 study in archives of general psychiatry suggested that discharged psychiatric patients without substance abuse symptoms are no more likely to commit violence than others without substance abuse symptoms in their neighborhoods, which were usually economically deprived and high in substance abuse and crime. the study also reported that a higher proportion of the patients than of the others in the neighborhoods reported symptoms of substance abuse. findings on violence committed by those with mental disorders in the community have been inconsistent and related to numerous factors; a higher rate of more serious offences such as homicide have sometimes been found but, despite high-profile homicide cases, the evidence suggests this has not been increased by deinstitutionalisation. the aggression and violence that does occur, in either direction, is usually within family settings rather than between strangers. the argument that deinstitutionalization has led to increases in homelessness can also be viewed a misconception with some suggesting a correlative rather than causative relationship between the two. it has been argued that in united states, loss of low-income housing and disability benefits are the core causes of homelessness historically and placing the blame on deinstitutionalization