“A Bold New Approach”: Deinstitutionalization and the Restructuring of Mental Health Care in the United States, 1945-1981
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On February 5, 1963, President John F. Kennedy delivered a message to the U.S. Congress calling for “a bold new approach” to the twin problems of mental illness and developmental disabilities.1 For years, hundreds of thousands of mentally ill individuals languished in state-run psychiatric hospitals, frequently receiving custodial care at best, or more often outright abuse or neglect. Throughout the 1940s and 50s, a number of exposés were published across the country detailing the horrific conditions that America’s most vulnerable citizens were forced to endure. The authors demanded that the government take action to reform mental health care and end the suffering in state institutions. The vast majority of state mental hospitals were overcrowded, underfunded, and understaffed. Even well-meaning doctors and nurses felt there was no way for them to help patients who had the potential to return to society. Without a drastic change in the system, the number of individuals in state institutions would continue to grow and conditions would deteriorate further. Kennedy’s approach called for the introduction of nationwide community-based mental health care centers. This plan would allow America’s mentally ill citizens to live in the community while receiving treatment. The introduction of antipsychotic drugs like Haldol and Thorazine in the 1950s made it appear possible “for most of the mentally ill to be successfully and quickly treated in their own communities and returned to a useful place in society.”2 Kennedy’s plan declared that the federal government should finance the establishment and operation of mental health centers and ease the financial burden of states. For most Americans, deinstitutionalization seemed to be both a financial and moral imperative. Reports given by reform-minded psychiatrists implied that new medications would treat the worst symptoms of mental illness, allowing individuals with severe mental illness to live safely in the community. The promise of deinstitutionalization did not materialize. On a policy level, mental illness was viewed as a cause and byproduct of problems in society like poverty, juvenile delinquency, and unwed motherhood. On a psychiatric level, many professionals pushed for mental illness to be seen as “problems in living,” or an individual’s inability to cope with the daily stresses of life. While the National Institute of Mental Health and other government advocates emphasized the need for prevention, that focus proved difficult. This work examines the premises underlying the process of deinstitutionalization and the broader social context in which it occurred in order to better understand how this initiative failed to produce a comprehensive system of community care.