David Mechanic and Gerald N. Grob
Rhetoric, Realities, and the Plight
of the Mentally Ill in America
Deinstitutionalization of persons with mental illnesses is now a fact of life. Many have criticized its consequences and insisted that the policy has been disastrous (Isaac and Armat 1990). Few, however, have demanded that we return to institutional solutions for care of persons with mental illnesses. Public mental hospitals in the United States have largely been emptied, with only approximately 54,000 patients in long-term state mental hospitals at the beginning of the twenty-first century. In today's context, however, the meaning of deinstitutionalization has changed; it now refers to barriers to long-term inpatient residence. Patterns of care have changed radically as well. Hospital care is now largely limited to short-term admissions during florid episodes of disorders or when patients are believed to pose significant risks to themselves or others.
The debates about deinstitutionalization continue with wide appreciation that realities have deviated greatly from the intentions and expectations of its proponents. Few look back on its history as one of policy triumph, and retrospective examination suggests that many of the same factors that diverted earlier aspirations still distort policy today, although in different ways. Most important among these are the effects of financing programs and incentives on locations, types, and patterns of treatment, the expansion of concepts of mental illness that obfuscate the differences between serious mental illness and other forms of psychological distress, the confusion between wishful thinking about prevention and evidence of its efficacy, and the role of advocacy and ideology in shaping medical policy. Understanding public mental-health policy also requires attention to the cross-cutting issue of the tensions between federal and