Balancing the pendulum: Rethinking the role of institutionalization in the treatment of serious mental illness
Katherine Warburton and Stephen M. Stahl
January 16, 2020
Cambridge University Press
Balancing the pendulum: Rethinking the role of institutionalization in the treatment of serious mental illness
Intro
The history of serious mental illness (SMI) is grim, from a cultural as well as a treatment perspective. The conditions of individuals with psychotic disorders have swung, like a pendulum, from institutional neglect to community neglect and back again over the past several hundred years. At the core of treatment failure is a failure in mental health policy and funding, with the result usually framed as the degree of human institutionalization in jails, prisons, and asylums. In the middle of the 19th century, institutions designed to deliver moral treatment were considered the humane answer to care properly for the SMI population. By the mid-20th century, those same, now overcrowded, institutions were blamed for the horrible conditions of mistreatment of individuals with SMI. Now, as we approach the middle of the 21st century, deinstitutionalization (the answer to the cruel asylums) is purportedly at fault for homelessness, lack of treatment, and criminalization. As the pendulum swings, we are hearing cries to “bring back” the asylums.
Care providers currently working in the trenches delivering public mental health services to people with SMI know that society has failed to care adequately for this group. Individuals living with mental illness are now often living on the open streets or incarcerated, and on average die 20 years sooner than the rest of us. An examination of the history of the approach to people with SMI across time and geography indicates that we are just one data point on a cyclical pattern of treatment and policy failure through time.
Figure 1 is an oversimplification, but illustrates the issue if you consider the current state of homelessness, criminalization, forensic institutionalization, and incarceration of people living with SMI in the wake of deinstitutionalization. The criminalization crisis is currently reaching the tipping point where it will begin to drive changes in policy. And so, we are at risk of watching the familiar pendulum swing in the same pattern: lock them up, let them out, lock them up. When a society fails to take care of humans with SMI in either setting, the pendulum will continue to swing between these two extremes. The social choices have historically been to either neglect them in state hospitals and prisons or to let them fall apart in the community (until such time as they are incarcerated or dead).
