No Place To Go

...The first half of the policy has been pursued with enthusiasm...

...Amitai Etzioni is Professor of Sociology at Columbia University and Director of the Center for Policy Research...

...A New York study found that 29 per cent of released mental patients returned to the asylum within six months, and about half returned eventually...

...Such conditions have existed for years, however, and they do not in and of themselves suggest deinstitutionalization as the obvious response...

...But there has been only token development of the community care needed to adequately service the huge numbers being discharged from mental hospitals (and from other institutions...

...Of 2,600 patients, 500 to 600 had ended up in nursing homes, with the number rising rapidly...

...As of late 1973, the National Institute of Mental Health counted only 209 psychiatric halfway houses in the entire country (as compared, for example, with the nation’s 23,000 nursing homes...

...To Thomas Szasz, mental illness is a “myth...

...A Poor Fit Follow-up on the fate of those released from institutions suggests that the fit between the rhetoric and the reality of deinstitutionalization is a poor one...

...To cite only one of quite a few examples, in January 1976, following a series of hearings during which medical and health authorities as well as prisoners described the “snake-pit” conditions in Alabama prisons, U.S...

...Ex-mental patients who live on their own frequently end up eking out a lonely existence in a welfare hotel in a deteriorating, highcrime neighborhood...

...Jerome Miller moved on in 1973 to become head of the Illinois Department of Children and Family Services, where he ordered his staff to cut the number of children in treatment centers and other institutions by one third...

...A realistic modesty about the precision of our powers of prediction, however, is one of the best arguments against heavy reliance on involuntary commitment...

...Although each has lzis or her distinctive personal position, all can be characterized as influential “abolitionists ”-that is, people inclined strongly toward the position that institutional inmates would be better off if institutions were abolished, rather than decreased in number and size and upgraded in services...

...When the Willowbrook school for the retarded was closed, New York state officials complained about how few parents would take their children back-or even give consent for foster care placement...

...Facilities for the retarded are so understaffed that basic custodial care, let alone education or training, is barely being provided...

...Psychiatric services are very seldom available...

...For others, all three options are at best deeply problematic...

...In contrast, new social pokcies still tend, all too often, to go directly from concept to implementation...

...The widespread acceptance of deinstitutionalization, however, raises important questions about it...

...Whether these facilities are an improvement over the back wards of state mental hospitals is questionable...

...Generally their arguments are based less on research than on perscinal observation, experience, and empathetic insight...

...District Court Judge Frank M. Johnson, Jr...

...Many spend their days in a daze, for the most part harmless but also helpless and hopeless...

...If we now realize that many people who are institutionalized should not be, the experience of releasing large numbers of them stands as a powerful argument for the existence of some, albeit drastically improved , institutions...

...Enormous numbers of mental patients have thus been released into communities they are not prepared to cope with and that are not prepared to cope with them...

...Government care and safety standards are low, especially for boarding homes, yet most homes do not meet them...

...The lesson is that the social world is complicated above all because people have a variety of needs and capacities, which require accordingly a variety of responses: some people will continue to require institutionalization, some can have their needs met in halfway houses, and some can live at home...

...In still other cases, the family views caring for the former inmate as a burden that is accepted only reluctantly and resentfully...

...To make matters worse, there is absolutely no accountability...

...By 1973 there were only about 7,000 patients left in California’s mental hospitals (down from 22,000 in 1967...

...Finally, deinstitutionalization has found great favor among legislators and administrators because of its expected savings for taxpayers...

...The parents claimed that they had previously tried to care for their children at home and this had proved impossible, and that they did not believe that children with such serious handicaps could be adequately served or supervised in foster homes...

...Cynthia Barnet and Philip Leaf, two University of Wisconsin graduate students, followed up the fate of patients released from Bryce State Hospital...

...Prisons are grossly overcrowded and fail to rehabilitate...

...Thus, for instance, Corrections magazine reported that when Jerome Miller was in the midst of closing Massachusetts training schools right and left and needed places to park the kids, just about anyone could walk into his office with just about any innovative-sounding scheme and leave with a contract to provide “community care...

...For example, between 1969 and 1974 Wisconsin’s mental hospital population dropped 84 per cent, North Carolina’s 79 per cent, and Alaska’s 78 per cent...

...Deinstitutionalization” is one of the trendiest new policies in recent y e h . Its concept is a simple one: state institutions-from mental hospitals to training schools for the retarded to reform schools for juvenile delinquents and correctional facilities for adult criminals and drug addictsshould be drastically cut back and their inmates given similar services “in the community...

...What are the main forces propelling it...

...Parents worry about the one or two ex-inmates who may not be harmless, and about the “birds of prey” (muggers, drug-pushers) that ex-inmates attract...

...and perhaps worst of all, that they exaggerate the seriousness of the problem as a means of continually justifying the need for their existence...

...One man murdered his wife and three of his five children before killing himself...

...no states require boarding home operators to file cost reports to show how money is being used...

...And television exposure of conditions at the Willowbrook school, a large state facility for the retarded on Staten Island, led to a courtsupervised agreement to transfer the institution’s 2,000 inmates back to the communities they came fromeither back to their parents, to foster homes, or to small community treatmen t facilities...

...Fear-oftentimes uninformed and downright bigoted, but in other cases quite understandablecauses communities to oppose the construction of needed halfway houses and treatment centers...

...Where attempts have been made to cut security precautions to a minimum to create a setting more conducive to effective treatment, behavior of those people who cannot be controlled-who, even if few, may be highly dangerous, or at least very abusive-has resulted in public outcry and political backlash...

...ruled that prison life in Alabama amounted to “cruel and unuSual punishment” and was therefore in violation of the Eighth Amendment...

...Hastily created and illsupervised by state officials, many are in the hands of fast-buck artists with scanty qualifications to run such programs...

...Overnight Closings Recent scandals involving the high cost and poor quality of nursing home care have prompted much interest in deinstitutionalizing elderly nursing home residents...

...His latest book is Social Problems, just published by Ben tice-Hall...

...Instead, for the majority of released inmates, most of whom are ex-mental patients or former residents of institutions for the retarded, “community care” means one of three things: living with relatives, isolated existence on one’s own, or entering a boarding care or nursing home...

...To be effective, deinstitutionalization has to be a two-part policy: getting the inmates out of the institutions, and then finding alternative means of caring for them...

...For those ex-mental patients incapable of functioning wholly independently and who cannot rely on relatives, nursing and boarding care homes are virtually the only altemative...

...Above all, what we need most is to curb our enthusiasm for oversimplification and learn to live with, and respond to, the complexities of the world...

...A New York study found that 25 per cent of welfare hotel residents were ex-mental patients...

...Thus, the current head of the Massachusetts Department of Youth Services has conceded that more “secure slots,” in institutional settings, are required for “heavy offenders...

...Meanwhile, on the other side of the country radical reformers began pursuing a similar policy concerning juvenile delinquents...

...With so few community care programs of any kind, let alone ones of adequate quality , deinstitutionalized people returning to the community tend to be left with little or no care...

...In California, a small but still alarming number of deinstitutionalized mental patients ran amok and killed people...

...Edward Koch calculated that at-home services now costing $12,000 to $13,000 a year for people in nursing homes would be lower, between $3,000 and $9,000 each a year...

...There is ample evidence that many persons in nursing homes need neither round-the-clock supervision nor the kinds of highly skilled medii81 care that can best be provided in an institution...

...No Place To Go by Amitai Etzioni In the engineering of new techn o 1 o g y - spacecraft, missiles, even toys-it iS standard practice to move systematically from a theoretical concept to a :mall-scale model, subject it to testing and modification, and then bdild a few full-scale prototypes before mass production is authorized...

...But not holding large numbers of almost certainly harmless though perhaps marginally functional persons in institutions against their will is quite different from shipping them out whatever their wishes, or closing down so many institutions that, for those who really need it, access to such care is severely curtailed...

...The facts are well known: for years the back wards of state mental hospitals have been full of oversedated zombies, warehoused and forgotten...

...Psychiatrists have a difficult time advising judges as to which mental patients are potentially violent and hence dangerous to the community and may well require institutionalization...

...Rethinking the Approach As the defects of deinstitutionalization have become more evident, several of the states that pioneered the policy have had to retrench and rethink their approach...

...What are its merits, and the limits of its applicability...

...Deinstitutionalization was pioneered first in the late sixties in California, where Governor Ronald Reagan welcomed it as a conservative strategy for cutting back on big government and big state budgets...

...By 1974, in the ten states where deinstitutionalization of juvenile delinquents was most advanced, 48 per cent of the delinquents were not in institutions...

...For others, mental patients and juyenile delinquents in particular, family tensions have played a major role in creating the problems that led to institutionalization in the first place...

...NO more than that such a simple solution should ever have been so uncritically adopted and so sweepingly applied...

...Squalor and Brutality By far the strongest argument for deinstitutionalization is based on the deplorable conditions and nonexistent services that are characteristic of many institutions...

...They say that institutions are dehumanizing...

...One line of litigation has pursued their equal right to a free public school education along with children of normal 1.Q...

...Return to a loving, accepting family is highly desirable, but many long-time inmates have no families...

...Another patient, who had protested being released, saying he could not cope on the outside, went on a spree and murdered 17 people...

...Home health agencies and day centers could in many instances provide the services the elderly require under more humane, less confining circumstances, with less potentidl for abusive practices, and at lower per-person cost--if such services existed...

...In California, scahdals in the for-profit boarding care industry that grew up to provide living arrangements for released men tal patients sparked a state senate investigation whose final report was highly critical o f d einstitutionalization...

...Everybody will be better off the ex-inmates will be treated more htmianely and have a better chance for rehabilitation, and the public will pay less for its care and get more for its money...

...that they foster crippling dependency...

...Whatever is not spent becomes profit...

...overtranquilization is every bit as common as in state hospitals...

...First are the civil libertarians, who in recent years have increasingly brought the low level and poor quality of services provided in state-run institutions to the attention of the courts...

...State governments have shown a great interest in deinstitu tionalization, because care for residents in state institutions is typically paid entirely out of the state budget, while the cost of “community fa~ilities’~-halfway houses or boarding houses or foster care-are to varying degrees paid for by federal funds funneled through Medicare, Medicaid , or Supplemen tal [Social] Security Income (SSI...

...As head of the Massachusetts Youth Services Department, Jerome Miller, an impassioned social-workprofessor-turned-administrator, set about closing reform schools, his aim being “to tear down the system to the point where Heinrich Himmler and the SS couldn’t put it back together again...

...exposes have disclosed squalor and brutality right out of a Dickens novel in some state training schools for juvenile delinquents, which have gained a reputation as trade schools of crime...

...In another case, a woman who was refused institutionalization beheaded her daughter and son...

...Jessica Mitford sees prisons and prison reform as a con game...

...The trend has been to farm them out to myriad small projects under private-sector auspices...

...To a large extent, the track record of deinstitutionalization is a disappointing and even frightening one, one that is becoming another example of reformers charging too blindly in one direction and ignoring the consequences of the charge...

...In releasing a Senate long-term care subcommittee report on the boarding home industry, Senator Frank Moss, the subcommittee’s chairman, said, “Operators understand that the way to make a profit is to cut back on food, staff, bedding, and other vital services...

...Unfortunately, however, it must be conceded that our current ability to predict who will do well in a particular kind of institutional setting is far from outstanding...

...As an idea, deinstitutionalization became popular in the social reform climate of the 1960s, but from the start one of its strengths was its appeal to both liberals and conservatives...

...Their legal arguments center around such violations of rights as unjust imprisonment, deprivation of liberty without due process, and cruel and unusual punishment-all, they say, are implicit in the involuntary confinement of persons in institutions that fail to provide decent living conditions or sufficient opportunities for rehabilitation or cure...

...The current high rate and ill effects of revolving-door placements could be cut back by adopting policies that recognize from the start that a sizable group of those needing services will continue to require institutiondization, while a substantial majority of the rest will require extensive support services simply to stay on the outside and avoid being abused or exploited, let alone cope successfully with life’s pressures...

...As a result, the spread of a new policy, which reflects the mood of the times, often resembles nothing so mud as a fashion wave...

...Rather, the policy has gained momentum lately due to the efforts of three vocal and energetic constituencies, each with its own rationale for promoting deinstitutionalization...

...We have looked at the consequences of deinstitutionalization for ex-inmates, but the policy has an impact, often negative, on the community as well...

...As of 1968, New York began releasing mental patients so fast that by 1974, there were 46,000 fewer patients in the state’s mental hospitals than there had been a decade earlier...

...Before Governor Reagan’s term was out he had go abandon plans for further mental hospital closings, reopen two facilities, and increase the state budget for mental institutions...

...Indiana’s 1973-74 biennial budget called for a cut of $2.4 million in institutional expenditures because of a planned transfer to community care...

...He then announced that the Court was prepared to close every prison in the state if officials did not correct the conditions that had caused what the judge characterized as “the rampant violence and jungle atmosphere .” Retarded and severely physically handicapped children have also been affected by court decisions...

...Does this mean that deinstitutionalization has shown itself a failure and should be abandoned...

...Laing, Thomas Szasz, Ivan Illich, and Jessica Mitford...

...For quite a few former inmates who have been unnecessarily institutionalized, one of these options works, so for them, deinstitutionalization is a good policy...

...In the case bf facilities for drug addicts and juvenile delinquents, security precautions can result in mini-fortresses, walled off from all community contact...

...Nationwide the decrease was 44 per cent...

...In youth services, crash deinstitutionalization, involving the virtually overnight closings of large state training or reform schools in bureaucratic surprise attacks, has frequently meant that officials had to find alternative placement for large numbers of youngsters all at once...

...The idea caught on in other states...

...Much more encompassing in their critique of institutions than the civil libertarians are such social essayists as Paul Goodman, Erving Goffman, R.D...

...For many exmental patients the situation is sink or swim-either fend for oneself without any suppdrt services (other than welfare) or be reinstitutionalized...