Reflections on Deinstitutionalization

Harold Pollack offers an acute analysis of the effect of deinstitutionalization in his latest Washington Post piece. Many commentators have pronounced the policy a blanket success or a complete failure, but as Harold points out, it’s more complex than that:

On the whole, deinstitutionalization improved the lives of millions of Americans living with intellectual and developmental disabilities (I/DD) — albeit with many exceptions. These policies allowed people to live with proper support, on a human scale, within their own communities. Second, deinstitutionalization was far less successful in serving the needs of Americans suffering from severe mental illness (SMI) — again, with many exceptions.

The vision of the community mental health movement was that institutionalized individuals would be moved to the least restrictive possible residential setting. They would prosper, and the rest of society, by having more regular contact with them, would become less fearful and stigmatizing. This happened some of the time, but as Harold argues it was more common for people I/DD. In contrast, people with SMI were more likely to end up with marginal or no housing and few needed few support services.

I agree with his analysis, but would add one gloss about the standard by which we judge the effects of deinstitutionalization on people with SMI. The heartbreaking sight of a raggedly-dressed man with schizophrenia screaming at shadows on a windy street corner is not by itself proof that deinstitutionalization was bad policy. Year after year in place after place, government audits and investigative journalism reports found widespread abuse, cruelty and inhumanity in state mental hospitals.

If we assume that the pitiable man with schizophrenia on the corner would be in a high-quality, safe, well-staffed state mental hospital if only the country hadn’t deinstitutionalized, we are inventing a past that rarely existed. Granted, it may bother the rest of us more that someone is sleeping in their own waste on the street than when the same thing happens in a back ward of an institution, but that’s because only in the former case do we have to look at such suffering, not because the person themselves is necessarily worse off.