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From Asylum to Community

From Asylum to Community: Mental Health Policy in Modern America

Gerald N. Grob
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    From Asylum to Community
    Book Description:

    The distinguished historian of medicine Gerald Grob analyzes the post-World War II policy shift that moved many severely mentally ill patients from large state hospitals to nursing homes, families, and subsidized hotel rooms--and also, most disastrously, to the streets. On the eve of the war, public mental hospitals were the chief element in the American mental health system. Responsible for providing both treatment and care and supported by major portions of state budgets, they employed more than two-thirds of the members of the American Psychiatric Association and cared for nearly 98 percent of all institutionalized patients. This study shows how the consensus for such a program vanished, creating social problems that tragically intensified the sometimes unavoidable devastation of mental illness. Examining changes in mental health care between 1940 and 1970, Grob shows that community psychiatric and psychological services grew rapidly, while new treatments enabled many patients to lead normal lives. Acute services for the severely ill were expanded, and public hospitals, relieved of caring for large numbers of chronic or aged patients, developed into more active treatment centers. But since the main goal of the new policies was to serve a broad population, many of the most seriously ill were set adrift without even the basic necessities of life. By revealing the sources of the euphemistically designated policy of "community care," Grob points to sorely needed alternatives.

    Originally published in 1991.

    ThePrinceton Legacy Libraryuses the latest print-on-demand technology to again make available previously out-of-print books from the distinguished backlist of Princeton University Press. These paperback editions preserve the original texts of these important books while presenting them in durable paperback editions. The goal of the Princeton Legacy Library is to vastly increase access to the rich scholarly heritage found in the thousands of books published by Princeton University Press since its founding in 1905.

    eISBN: 978-1-4008-6230-6
    Subjects: Psychology

Table of Contents

  1. Abbreviations Used in Text
    (pp. xvii-2)
  2. Prologue
    (pp. 3-4)

    On the eve of World War II the framework of mental health policy in the United States appeared stable. At its center was an extensive system of public mental hospitals whose foundations had been laid in the early nineteenth century. These institutions were responsible for providing both care and treatment for all mentally ill persons irrespective of their ability to pay the high costs associated with protracted institutionalization. By 1940 the resident population of state mental hospitals had reached 410,000; an additional 59,000 patients were in veterans’, county, and city institutions. That year 105,000 persons were admitted to state hospitals...

  3. CHAPTER ONE The Lessons of War, 1941–1945
    (pp. 5-23)

    World War II marked a watershed in the history of mental health policy and the evolution of American psychiatry. Many psychiatrists who served in the military came to some novel conclusions. They found that neuro-psychiatric disorders were a more serious problem than had previously been recognized, that environmental stress associated with combat contributed to mental maladjustment, and that early and purposeful treatment in noninstitutional settings produced favorable outcomes. These beliefs became the basis for the claims after 1945 that early identification of symptoms and treatment in community settings could prevent the onset of more serious mental illnesses and thus obviate...

  4. CHAPTER TWO The Reorganization of Psychiatry
    (pp. 24-43)

    Before specific substantive policy innovations could even be considered, psychiatrists had to create a more effective organizational vehicle to promote their case for change. Toward the close of World War II, therefore, a group of younger figures—many of whom had served in the military—launched a searching evaluation of the nature and structure of their specialty and began to consider a series of far-reaching proposals for change. At times the intensity of the discussions created rival groups and ruptured long-standing personal and collegial relationships. The dialogue ranged over a variety of issues. What was the etiology and nature of...

  5. CHAPTER THREE Origins of Federal Intervention
    (pp. 44-69)

    The experiences of World War II and the organizational and conceptual changes within psychiatry, admittedly important, could hardly have promoted major policy and structural innovations by themselves. The lessons of World War II were not fundamentally dissimilar to those of World War I, and even the basic principles of psychodynamic psychiatry had their roots in earlier decades. That change had not occurred prior to 1940 was but a reflection of a quite different context. In 1920 relatively few psychiatrists had been exposed to psychodynamic or psychoanalytic principles, and the ideal of institutional employment still prevailed. More important, the expanded role...

  6. CHAPTER FOUR Mental Hospitals under Siege
    (pp. 70-92)

    The impetus for change in the 1940s and 1950s came from individuals and groups somewhat remote from state governments and public mental hospitals. Yet if their hopes and visions were to be realized, they would have to persuade state officials to support and to implement new commnity-oriented approaches. Such a task presented formidable difficulties. Under America’s federal system, power is divided between national and state governments. The Tenth Amendment explicitly provided that powers not delegated to the national government were “reserved to the States respectively, or to the people.” Centuries of experience, both preceding and following the adoption of the...

  7. CHAPTER FIVE The Mental Health Professions: Conflict and Consensus
    (pp. 93-123)

    The growing hostility toward a hospital-based policy, the expanding role of the federal government, and the dominance of psychodynamic and psychoanalytic concepts had a profound impact upon the structure of the mental health professions. New concepts of health and disease, an emphasis on psychological therapies, and a commitment to environmental changes implied broadened and more responsible roles for such specialties as clinical psychology, psychiatric social work, and psychiatric nursing. Their growth was also fueled by the gradual weakening of kinship and family networks and religious institutions, which in the past had provided the major supports for individuals requiring some sort...

  8. CHAPTER SIX Care and Treatment: Changing Views
    (pp. 124-156)

    Marked enthusiasm for changes in mental health policy characterized the postwar years. Yet the elements that promoted receptivity toward innovation—the lessons drawn from wartime experiences, the shifts in the structure and ideology of the mental health professions, the altered role of the federal government—did not by themselves define demonstrably more effective ways of providing care and treatment for mentally ill persons. Ideals, hopes, and aspirations had to be translated into concrete programs and policies, and these, in turn, had to be blended and transmuted in the crucible of experience. In the final analysis, the criterion of success was...

  9. CHAPTER SEVEN Changing State Policy
    (pp. 157-180)

    The ferment and debates over the proper shape of mental health policy in the postwar years were not simply abstract intellectual exercises. Ideas, after all, often have profound consequences; they can mold policies and shape the thinking of the general public as well as medical and political elites. It would have been surprising, therefore, if newer concepts of mental illnesses, therapies, and alternatives to traditional institutional care had had no impact on public policy.

    By the 1950s signs of change were already evident. The postwar exposes of severe deficiencies in the nation’s public mental hospitals and their constantly rising patient...

  10. CHAPTER EIGHT A National Campaign: The Joint Commission on Mental Illness and Health
    (pp. 181-208)

    The pace of change in the decade following 1945, however rapid, seemed cumbersome and slow to impatient contemporary activists. The decentralized nature of the American political system meant that the struggle to transform public policy had to be fought in each individual state. A unified campaign was extraordinarily difficult, given the fact that policy and appropriations were the responsibility of state legislatures and governors. Success might come in New York and California where a large concentration of psychiatric personnel and services existed and where a commitment to the welfare of the mentally ill had a long-standing tradition. In other states,...

  11. CHAPTER NINE From Advocacy to Policy
    (pp. 209-238)

    The ideals that people pursue in seeking social change and the realities that subsequently emerge rarely correspond. This generalization is particularly applicable to the evolution of mental health policy in the 1960s.Action for Mental Healthrepresented the work of individuals determined to improve the lives of the mentally ill and the psychologically troubled. Its authors believed the time was ripe for dramatic changes; their goal was not merely to reshape traditional mental hospitals, but to dramatically expand community services. Aware of the rapidly growing role of the federal government in health and biomedical research, they sensed a golden opportunity...

  12. CHAPTER TEN From Institution to Community
    (pp. 239-272)

    Community mental health centers represented a radical policy innovation. In many respects they were an outgrowth of the continuum concept of mental illnesses and the prevailing faith in the superiority of community care and treatment. Indeed, by the early 1960s the termcommunity psychiatryhad come into use to describe the intellectual and institutional changes that were transforming mental health policy and practice. The presumption was that a national program to construct centers would ultimately make available integrated and coordinated mental health services in defined geographical areas. Centers would facilitate early identification of symptoms, would offer effective preventive treatments that...

  13. CHAPTER ELEVEN Challenges to Psychiatric Legitimacy
    (pp. 273-301)

    By the early 1960s psychiatric activists seemed on the verge of achieving their long-sought goals. A combination of federal action and thirdparty insurance had seemingly created a series of alternatives to mental hospital care and treatment. New therapies—psychological, psychosocial, biological—offered hope to those who had traditionally languished in the back wards of public hospitals. “We are now in a period of hopeful change,” observed Harry C. Solomon in his APA presidential address in 1958 in which he described the present and future trends that were transforming the very structure of the specialty. “An atmosphere of greater optimism about...

  14. Epilogue
    (pp. 302-304)

    In the early nineteenth century, Americans pursued institutional solutions to resolve complex social problems. To activists such as Horace Mann and Dorothea L. Dix, the mental hospital symbolized the means by which society fulfilled its moral and ethical obligations to mentally ill persons requiring assistance. Such institutions, they insisted, benefited the community, family, and afflicted individual by providing care and treatment irrespective of ability to pay the high costs associated with protracted hospitalization. In the succeeding century the mental hospital became the foundation of a policy that guaranteed access to care and treatment for the mentally ill. From modest beginnings,...