Throughout 1974, advocates and mental health professionals were debating the merits and shortcomings of psychiatric institutions for people with mental illness. The previous year, psychologist David Rosenhan published an article in Science, “On Being Sane in Insane Places,” which was influential in demonstrating that psychiatric professionals were overly eager to diagnosis people as mentally ill. It also showed that institutionalization may work against the positive mental health outcomes it was designed to achieve.
Mr. Rosenhan wrote, “It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals…The consequences to patients hospitalized in such an environment – the powerlessness, depersonalization, segregation, mortification, and self-labeling – seem undoubtedly counter-therapeutic.”
The experiment involved the use of eight “pseudopatients” who gained admission to twelve psychiatric institutions by simulating symptoms of schizophrenia. The institutions included both public and private, urban and rural, and underfunded and large budget institutions. In all twelve institutions, the pseudopatients were incorrectly diagnosed. They were released only on the condition that they admit that their mental illness was only in remission, that it would never be cured, and that they continue to take antipsychotic medications.
The experiment showed that institutionalization involved severe invasions of privacy, rampant boredom, and exposure to traumatic interactions between staff and patients, all of which might threaten the mental stability of a person attempting to recover. It gave credence to a growing movement that had been pushing for reform to the oppressive system of psychiatric institutionalization, and for community-based solutions for people with mental illness.
One year later, the U.S. Supreme Court, in the landmark case O’Connor v. Donaldson, ruled that no state may constitutionally confine any non-dangerous individual who is capable of surviving safely in freedom by themselves or with the help of willing and responsible family members or friends. The Supreme Court determined that the state cannot confine people with mental illness only on the presumption of giving them a higher standard of living than they might enjoy in the community. In addition, a 1973 Supreme Court ruling in Souder v. Brennan determined that psychiatric hospitals could not require work from patients unless they were paid minimum wage. This decision made many institutions financially unstable.
Communities were not prepared for the consequences of O’Connor as state psychiatric institutions began rapidly down-sizing or closing. Community mental health programs and community based housing were inadequate for the influx of poor people with mental illness and extremely low incomes, contributing to a sharp rise in homelessness among single adults.
Advocacy to end unnecessary institutionalization led to another important Supreme Court decision in Olmstead v. L.C. in 1999. In that ruling, the Supreme Court found that the institutionalization of persons with disabilities who were ready to return to the community was a violation of Title II of the Americans with Disabilities Act (ADA). In its decision, the court found that indiscriminate institutional placement of persons who can handle and benefit from community settings perpetuates unwarranted assumptions that persons isolated in institutions are incapable or unworthy of participating in community life. The court also found that confinement in an institution severely diminishes everyday life activities, including “family relations, social contacts, work options, economic independence, educational advancement, and cultural enrichment.”
Because of the Olmstead decision, many states are now in the process of either: implementing “Olmstead Plans” that expand community-based supports, including new integrated permanent supportive housing opportunities; or implementing Olmstead-related Settlement Agreements that require thousands of new integrated permanent supportive housing opportunities to be created in conjunction with the expansion of community-based services and supports.
Advocates have spent much of the past 40 years striving to gain the resources necessary to provide housing and supportive services to all low income people with mental illness. Recently, the expansion of permanent supportive housing and housing first programs have had an impact on reducing homelessness for people with mental illness. The Affordable Care Act also provides expanded capacity for service providers to meet the needs of low income people with mental illness in a community-based setting.
David L. Rosenhan, “On Being Sane in Insane Places,” Science, Vol. 179 (Jan. 1973), 250-258, http://psychrights.org/articles/rosenham.htm
Torrey E. Fuller, “Deinstitutionalization: A Psychiatric ‘Titanic.’” Out of the Shadows: Confronting America’s Mental Illness Crisis. 1997. Excerpt at http://www.pbs.org/wgbh/pages/frontline/shows/asylums/special/excerpt.html
Chris Koyanagi, “Learning from History: Deinstitutionalization of People with Mental Illness as Precursor to Long-Term Care Reform.” Kaiser Commission on Medicaid and the Uninsured, http://www.nami.org/Template.cfm?Section=About_the_Issue&Template=/ContentManagement/ContentDisplay.cfm&ContentID=1375452007
Chronic Homelessness Policy Brief. National Alliance to End Homelessness, http://www.endhomelessness.org/pages/chronic_homelessness
More information about Olmstead is on page 191 of NLIHC’s 2014 Advocates’ Guide, http://nlihc.org/sites/default/files/2014AG-191.pdf