Deinstitutionalization and the Criminalization of Mental Illness

About half of the U.S. prison population suffers from a mental illness. According to Alisa Roth, author of Insane: America’s Criminal Treatment of Mental Illness, the lack of accessible treatment options contributes to the criminalization of mental illness. This can be attributed to deinstitutionalization, “the policy of moving mentally ill people out of large state institutions [e.g. public psychiatric hospitals] and then closing part or all of those institutions.”

Although deinstitutionalization was intended to better support those with mental illness, its improper execution has shaped the mental health crisis as we know it today.

In order to better understand and remedy this crisis, it is important to acknowledge the histories of institutionalization and deinstitutionalization, as well as the historical treatment of mental illness in the United States.

In the 1800s, institutionalization began and those in prison with a mental illness were removed from jails and transferred to psychiatric hospitals and asylums, as confinement in jails was considered inhumane. Although institutionalized care increased patient access to mental health services that the prison system could not provide, hospitals were often underfunded and understaffed. Serious issues arose as a number of reports highlighted poor living conditions and human rights violations within the institutionalized care system. By the 1950s, the push for deinstitutionalization generated efforts to move away from “asylum-based” care, and rather advocate for smaller, less isolated, community-oriented alternatives. The assumption was that community-based care would be more humane, therapeutic, and cost-effective than hospital-based care.

However, considerable unintended problems emerged from the deinstitutionalization movement, the most notable one being the criminalization of mental illness. Society turned back to the criminal justice system after deinstitutionalization, resulting in the inappropriate arrest and incarceration of those with mental illness instead of hospitalization. Since then, those with chronic and severe mental illnesses have not been receiving sufficient care and are instead living in jails, on the streets, or in other unacceptable and inhumane situations.

One tool that has been utilized to address the mental health crisis - in prisons, on the streets, and in the community in general - is medicine. It is important to note, however, that although medicine can serve to benefit one’s mental health, it should not be the ultimate solution; medicalization as a solution not only focuses the source of the problem on the individual rather than the social environment, but it can also work to increase the amount of medical social control over human behavior.

Instead of relying on the prison system and medicalization, there are alternative approaches that can better support those with mental illness:

1. Tailoring service planning to individual needs: Despite its unintended consequences, the initial efforts towards deinstitutionalization demonstrated the importance of individualized care for persons with a mental illness, who constitute a diverse and heterogeneous group of people.

2. Facilitating access to hospital care: Access to hospital care for all people with a mental illness at all times, and hospital care for those who need it as long as they need it, is absolutely essential to the success of deinstitutionalization.

3. Cultural relevance of services: Services must be culturally relevant. One-size-fits-all approaches are not appropriate for people who need mental health care.

4. Involving severely mentally ill persons in service planning: Experiences, values, and personal goals of individual patients must be acknowledged in the planning process. Consulting the families of those with a mental illness is also of extreme importance in the planning process.

5. Flexibility of service systems: Service systems must be flexible, open to change, and not restricted by preconceived ideology. Additionally, service systems must respond to clinical needs rather than allow preconceived ideologies to determine the kinds of services they provide.

6. Continuity of care in the community: It is crucial that people who have severe and long-term mental illness are able to receive services over a long period of time, and preferably from safe agencies and clinicians.

Currently, the criminal justice system has been the primary solution for the mental health crisis in the United States, resulting in the inappropriate and inhumane treatment of those with mental illness. By prioritizing community-based approaches and directing funding towards accessible treatment alternatives, we can realize the full potential of deinstitutionalization and work to improve the lives of our community members.

Primary Sources:

Conrad, P. (2007). The Medicalization of Society on the Transformation of Human Conditions into Treatable Disorders . Johns Hopkins University Press.

Hiday, V. A., & Burns, P. J. (2009). Mental Illness and the Criminal Justice System. In A Handbook for the Study of Mental Health (pp. 478–498).

Lamb, H. R., & Bachrach, L. L. (2001). Some Perspectives on Deinstitutionalization. Psychiatric Services (Washington, D.C.), 52(8), 1039–1045.

Torrey, E. F. (1997). Out of the Shadows: Confronting America’s Mental Illness Crisis. John Wiley.

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