International Journal of Psychosocial Rehabilitation
or Disowning Responsibility
more things change, the more they remain the same.'
Dr Hitesh C Sheth
Hospital for Mental
(2009). Deinstitutionalization or Disowning Responsibility
Journal of Psychosocial Rehabilitation. Vol 13(2). 11-20
Dr Hitesh C Sheth
The well intentioned deinstitutionalization movement which
started with a noble aim of treating and rehabilitating mentally ill
in community itself, so to reduce human rights violations and mitigate
sufferings, has almost failed to achieve its aim. Human right
violations which are
supposed to occur behind impregnable walls of mental hospitals, occurs
front of opened eyes of society, as a result of which mentally ill
patients suffers in jails, prisons,
shelter homes and streets. These problems can be solved by building
hospitals of a small size with an open ward facility and rehabilitation
providing employment to mentally ill patients, building more halfway
quarter way homes, daycare centers, sheltered workshops; providing a
facility to the improved patients; establishing the special courts
with the cases pertaining to mentally ills on a preferential bases and
with it enacting the laws to protect rights of mentally ill patients.
Deinstitutionalization, Trans-institutionalization, Human
rights violations, Mental Hospitals, Psychosocial Rehabilitation
trend is towards the deinstitutionalization of mental hospitals, means
the mentally ill patients in a community itself.
policy of was deinstitutionalization was started
in mid 1970. In 1963, it was believed that state mental hospitals were
often institutions for quarantining the mentally ill. In response to
perceived mental health problem,
Congress passed the Community Mental Health Centers Act to move
mentally ill out of prolonged confinement in overcrowded state
institutions into voluntary treatment at community mental health
centers. On Oct. 31, 1963
President Kennedy who
believed mental hospitals as 'snake pits' signed the Community Mental
Centers Act into law. The policy was said to be initiated by concern
mentally ill patients. But economic consideration was not rule out.
policy of deinstitutionalization has failed miserably. President Bush’s
Freedom Commission on Mental Health has described American public
system as “in shambles” (Mental Health Commission Report, 2003). The
from the National Alliance for the Mentally Ill's (NAMI’s) national
its membership were also disappointing, it illustrated the failure of
mental health system (Hall et al. 2003). Here I have tried to discuss
that how deinstitutionalization
movement is affecting the mentally ill patients in both developing as
the developed countries alike.
Deinstitutionalization or Trans-institutionalization:
n estimated 4.5 million Americans
from the severest forms of brain disorders, schizophrenia and
illness. And out of 4.5 million 1.8 million or 40 percent are not
treatment on any given day, resulting in homelessness, incarceration,
violence. And one of the reasons for this condition is a failure of the
policy (Fact Sheet, Treatment Advocacy Centre).So it is hardly
approximately one third of homeless persons suffer from severe and
mental illnesses (Morrissey & Dennis, 1986; Morrissey & Levine,
there is a correlation between the
and the downsizing of the state mental hospital
Same facts are
echoed in testimony of US Congressman Ted Strickland (Strickland,
According to him thousands of mentally ill patients are being dumped
state hospitals into communities that do not have the adequate services
receive them. These efforts known as "the deinstitutionalization
has resulted in trans-institutionalization, in which huge numbers of
ill individuals lands in jails, prisons, homeless shelters, and flop
wonder in one study done recently, around 40% inmates of ‘Beggar’s
having mental illness (Thakker et al; 2007).
The deinstitutionalization policy, which is
improperly implemented is acting like a misguided missile, because of
helpless and defenseless inmates of the mental hospitals begs and roams
roads and footpaths; takes refuge in shelter homes and beggar’s homes;
on streets and eats from garbage bins; are jeered in society and
verbally and sexually assaulted in alleys; languishes in jails and
prisons; shivers in cold and simmers in heat; and sleeps on a bed of
a blanket of sky. We have shifted problems of mental hospitals to the
jails and shelter homes. While making backyards of our mental hospitals
beautiful, we have made our streets ugly. The process of
has turned deadly. There seems to be some truth in a saying that
deinstitutionalization caused people to “die with their rights on”.
Dangers of Half Treated or Neglected Patients:
Deinstitutionalization which has now become synonym
for neglect was supposed to be about creating a new system of services
supports that would allow people with mental illness and mental
thrive in their communities outside of hospital settings during all of
times when they did not need hospital services (Bernstein,
purpose of the deinstitutionalization has not been served.
A study done by Klassen(1988) and
O’Connor(1990) found that approximately 25%-30% of male subjects with
one violent incident in their past are violent within a year of release
In 1993, sociologist Henry
Steadman studied individuals discharged from psychiatric hospitals. He
that 27 percent of released patients reported at least one violent act
four months of discharge. Another 1992 study, by Bruce Link of Columbia
University School of Public Health, reported that seriously ill
living in the community were three times as likely to use weapons or to
"hurt someone badly" as the general population. In recent times, a
MacArthur Foundation study done by
Silver(2000) found that people with serious brain disorders committed
many acts of violence in the period immediately prior to their
when they were not taking medication, compared with the
period when most of them were receiving assisted treatment.
According to a
1994 Department of Justice, Bureau of Justice Statistics Special
"Murder in Families," 4.3 percent of homicide committed in 1988 were
by people with a history of untreated mental illness. In 1998, law enforcement officers were more
likely to be killed by a person with a mental illness (13 percent) than
assailants who had a prior arrest for assaulting police or resisting
(Brown et al, 1998).
Swanson et al.
commenting on their ECA data, stated, public fear of violence committed
mentally disordered in the community is "largely unwarranted, though
totally groundless" (p. 769). This policy of deinstitutionalization has
rendered vast swathe of mentally ill patients-dangerous to self or
untreated or homeless.
Prisons or Mental Hospitals
There are more persons with
mental illness in jails and prisons than there are in state hospitals
1992).At least 9,000 people
with psychiatric disabilities are released annually from New York jails
and prisons without adequate housing or support services(Martell,1995).
Same facts are confirmed by researchers in other
way when they
found that as many as 40
50 percent of clients in the community mental health system
have a history of criminal arrest (Solomon, 1999).There is direct
between closing of mental hospitals and opening of new prisons.
the U.S. Department of Justice, 40 mental health hospitals have closed
past decade. During the same period, 400 new prisons have opened up
Olympian (Washington), October
The condition in a developing country like India is not so different. The writ
petition filed in Supreme Court of India by Ms Sheela Barse, a social
any children and adults were committed to jail in Calcutta
as lunatics were not mentally ill at all. (Supreme Court in Writ
No 237/1989.Sheela Barse versus Union of India and others, August
.Some were normal, some temporarily under stressor undergoing a phase
disturbance, and a few were mentally retarded. The commission appointed
by the Supreme
Court in response to this petition echoed the same facts. It said that
when a mentally
ill is sent to jail, which doesn’t managed them as a sick person, it
deprivation of liberty in several ways which is more excessive than is
either for the protection of the mentally ill person or for the safety
society. The commission also rued over the fact that jails had no
psychiatrist position. The visit of psychiatrist was weekly fortnightly
monthly but rarely daily. And some districts even lacked that facility. Former chairman of the
National Human Right Commission, Justice Ranganath Misra had issued
chief ministers of all the states some years ago, saying:” No mentally
person should be kept in any jail of the country after October
Still there is no improvement in condition.
The caseloads are
astronomically high, people
routinely fall out of the community mental health systems, and over the
the number of people with mental illnesses who are put in jails and
skyrocketed (Bernstein, 2007).
To Give Work In Appropriate Industry:
In Chinese language a synonym of difficulty is
opportunity. When giving a work to mentally challenged patients, our
be to transform their limitations into the strengths. This has been
demonstrated by Niseeth
Mehta, CEO of
‘Microsign Products’ a
company located in Bhavnagar, and produces plastic fasteners and
the quality conscious companies like ‘Volvo’, ‘Mercedes’, ‘Tata
Industries’. Although ‘People with Disability Act, 1995’ (PWD, 1995,
reserves three percent jobs for differently abled people. The company’s
percent staff is differently abled. The person whose hearing is
given a job at noisy engineering machine. Similarly intellectually
boys have been assigned a job-which any other person would find
which doesn’t affect their productivity and motivations. This doesn’t
one should compromise with a quality of work. The Company has almost
attrition rates and has met tough ‘ISO-9002’ and ‘QS-9000’ quality
person with autistic disorder, who does repetitive works or activities,
can be assigned
monotonous tasks, which normal person may abhor performing, but a
patient may enjoy it. The Day care centers, halfway homes and quarter
should be turn into the production houses and manufacturing units of
articles. A person who has recovered completely or has a single episode
schizophrenia can be appointed as a supervisor who can better empathize
understand the problems of mentally ill patients.
Advantage: Western countries:
According to facts compiled by Dr. Michael Friedman,
the Director of the Center for Policy and Advocacy of the Mental Health
Associations of NYC and Westchester
, from 2000
the 65 and older population in the US
will double from 35 million to 70 million and comprise about 20% of the
American population (Friedman, 2006). In the UK
in 2004, there were approximately 4 working age individuals (aged
every 1 person aged 65 and over. By 2056 this ratio is predicted to
about 2:1(Tetlow, 2006).
In the western countries, where the population is
stagnating or declining, providing an employment to the mentally ill
is a good strategy to counter a labor shortage which is going to arise
future. Employment provides not only a monetary recompense but also
benefits — non-financial gains to the worker which include social
status; social contacts and support; a means of structuring and
activity and involvement; and a sense of personal achievement
Thus by gainfully employing mentally ill patients we
can surmount the challenge of labor shortage, which is going to arise
future. Thus we can transform
not only individual’s limitations but also developed nation’s
Government of Gujarat
Policy: Without Tender Purchase:
The other measures that government can take are to
provide the incentives to the industries, which employ mentally ill or
challenged people. The Government of Gujarat (India
has given example worthy to emulate. It has issued a circular according
which goods and products made up by’ ‘Rehabilitation centers’ of
Mental Health’s’ can be purchased without issuing the tenders. The
benefit government is providing is tax benefit and free bus and railway
a concession rate which help to ease burden on patient’s family.
The other thing government can do is to provide subsidies
or tax sops to industries which employs differently abled people. And
efforts government is not losing any tax revenue, because it’s social
financial responsibility to rehabilitate the patients is carried out by
industries and in this way Government’s time and energy both are saved.
To Start More Day Care Centers and to Provide Housing
consistent evidence that access to housing and services significantly
hospitalizations, incarcerations, shelter use, and other expensive
interventions, there is a reluctance to adequately increase housing
Subsequently, people with mental illness are often
forced to wait
years in expensive and inappropriate institutions, prisons, homeless
and other emergency settings before they gain entry to housing
In a prospective study, Belcher (1989) found that 36% of the mentally
patients discharged from a state hospital became homeless, at least
temporarily, within six months of their discharge. Homeless people with
mental illness or substance abuse problems are more likely to return to
institutional care if they are not provided with adequate housing (M.
et al., 1987; Lipton, Nutt, & Sabatini, 1988; Wittman, 1989).
the Fair Housing Amendment of 1988 extended protections of federal fair
legislation to people with disabilities. It forbids discriminatory
effects of regulations concerning housing for mentally ill individuals.
situation is still grim.
there are at least 60,000 adults living with a psychiatric disability
throughout the New York State
who need housing, only 23,731 units of community-based housing have
developed for this population (Residential Indicator Report, 2004). As
and Burnam (1988) pointed out, we must concentrate on creating
rather than instituting treatment programs. Structure, support, and
may be particularly critical for the most vulnerable subgroups of the
population, and homeless persons themselves often seek these elements
The good rehabilitation
strategy would be to start the more day care centers attached with a
The strategy would
have a dual advantage, the
remain in the institution in a day time so their relative wouldn’t have
worry about him and in night he may return at his home so he can also
live in the
society. The patient would be gainfully employed so he would also have
satisfaction. The other thing is chance of relapse would also decreased
there is reduced chance of exposure to ‘Expressed Emotion (EE). As
patients in high expressed emotion settings were more
likely to relapse (56% compared with 17% for low expressed
emotion)(Leff & Vaughn, 1985).
A scheme may be designed for the
rehabilitation process for those who are not having any backing, or
support in the community. The Scheme may be on the basis of quarter way
(Supported Shared Home-Like Accommodation) for all patients ready to be
discharged, but are not being discharged due to family not taking them
lack of support in the community. They can be placed in a home-like
accommodation created on the hospital campus itself (Orders of Supreme
India in a Civil Writ Petition No 334/2001 & 562/2001,Saarthak
society and ANR versus Union of India and ORS,12th
accommodation could be an existing ward converted to have a home-like
environment, wherein patients can be taught of house keeping skills,
and can also be encouraged to take up responsibilities in the hospital
they should be paid for and then gradually encouraged to go to the
for the work.
Empowering Mentally Ills by Means of Appropriate Laws
The Government of India has passed 'People with
Disability Act', 1995(PWD ACT, 1995) to protect rights of mentally ill
patients. Next important step is a proactive role of court which by
judgments can set precedents that would help to mitigate suffering of
ill patients. In one such instance one employee who developed
terminated from the job. The Honorable Bombay High Court, upholding
of the PWD Act which deal with nondiscrimination, ruled that the
should either shift employee concerned to another post with the same
and service benefits or create supernumerary post until a suitable post
available(Times of India 17th November Ahmadabad Times Edition, 2004).
bold judgment was delivered by the Honorable Supreme Court of India on 24/10/2007
, in favor of
having mental illness. A supreme court of India
bench said that all cases will be closed against those mentally unfit
who have been in custody for periods more than the maximum punishment
prescribed for the offence allegedly committed by them. The Bench also
that those accused of serious offences that carry punishments of life
imprisonment or death will be released on bail if they have undergone
years in custody. (Indian Express 24th October 2007
). This will help to protect
people like Machal Lalung,
the 77 years old who spent 54 years in mental hospital at Gauhati, in
an under trial, despite of being declared 'fit to stand trial'
India, 11th January 2006 Ahmadabad Times Edition). He was however lucky
when Honorable Supreme Court of India came to know about this case they
promptly ordered to discharge him and also directed the government to
pay 3 hundred
thousand rupees of compensation. Many such laws and judgments are
protect rights of mentally ill patients
Other things that can be done is to
train the police on how to identify the mentally ill patients and
into available treatment facility. The government can also
fund jail and prison programs that screen,
evaluate and treat mentally ill inmates
Establishing ‘Mental Health Courts’:
of the important steps is to create mental health courts to direct
mentally ill defendants out of the revolving door of recidivism into
wrap-around treatment (Strickland, 2000). The America’s Law Enforcement
Mental Health Act (H.R. 2594), which has provision to establish '
Courts' in order to direct nonviolent mentally ill offenders out of
long term treatment, is right step in direction to protect right of
ill patients. Mental health courts are uniquely effective at reducing
recidivism of seriously mentally ill offenders because they use the
the criminal justice court to ensure that the defendants receive long
mental health treatment (Strickland, 2000).
Mental Hospitals with Adequate Staff Strength:
There are now 37 psychiatric
hospitals in India
with total bed strength of 18,024 (National Human Rights Commission,
beds are grossly inadequate in comparison to number of patients and
It has been seen that despite of development of new drugs, in 30 to 40
prognosis of schizophrenia is poor. As Lehman et al. (2004) noted,
"Despite the availability of these treatments, most patients remain
what symptomatic and/or vulnerable to relapse. Persevering impairments
and long-term outcome, while heterogeneous, still represents
morbidity for most patients”.
adult schizophrenia patients, outcome was
good in only 25
least partial remission, and 25 percent
hospitalized or grossly impaired (Mason 1995,
2001). When these chronically ill patients are kept in a community
in the institute, not only productivity of mentally ill patients is
but also productivity of his family members is affected.
The prevalence of schizophrenia
in general population is one percent, out of which 30 to 40 percent
have a poor
prognosis. It means that 0.3 to 0.4 percent of population is
mentally ill. If we assume that one chronically mentally ill patient
average 5 members of his family, leave alone his neighbors with whom he
resides. It means that about 2 percent of population is affected by the
directly or indirectly. MacGilloway et al (1997s) reported that 30 to
percent caregivers of psychotic patients had significant distress.
findings are similar to finding of Heru and Ryan (2002) study which
that 72% of caregivers of recurrent mood disorders report positively
The solution is to establish
more psychiatric hospitals with adequate staff strengths in each and
district and county rather than to build mammoth hospitals which
poor human right records and are difficult to manage. The bed strength
hospitals should be ideally between 50 to 100 patients. There should be
facility of open ward in which a family member can stay with patient.
hospital would be under an indirect vigil of public, which in turn
incidence of human right violations and would make atmosphere similar
of other general hospitals. The hospital should also have a
complex, which will help in rehabilitation of patients in society.
Assertive Community Treatment:
In case of patients who are improved but repeatedly
relapse into illness. Assertive Community Treatment is best solution
reduces admission rate and lessen burden on psychiatric hospitals.
includes a mobile
interdisciplinary treatment team comprising a psychologist, a
social worker, a case manager and a nurse that establishes close,
relationships with the individual, providing him with a high level and
services and supports if needed and backing away when he is doing
better(Berstein,2007). Mobile treatment at the doorsteps would also
patients who cannot come for regular follow up for treatment because of
inability to afford bus fare or train fare (Sheth, 2005).
The outpatient mental health system appears to be at least as
with criminally involved individuals as the criminal
is with mentally ill individuals and it shows almost a failure of
deinstitutionalization. We must wake up before problem created by
deinstitutionalization backfires and explodes on a face of society.
To prevent jails
and streets into the de facto asylums for
ill and to prevent the overburdening of
relatives of mentally ill patients this policy need rethinking. This
doesn’t mean we should deride the policy of deinstitutionalization,
formulated to counter the perils of institutionalized life, but process
deinstitutionalization should be with a humane face. The pendulum which
one extreme of institutionalization should no go to other extreme of
deinstitutionalization. The delicate balance between two processes is
for betterment of our patients. We must have patience till a sure cure
mental illness is found. When it is found, someday we would be able to
psychiatric hospitals like a TB sanatoriums of past, which were made
by discovery of effective drugs. The truth is, by helping the seriously
mentally ill we help ourselves. As one wise sage wrote, ‘No one will be
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