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We compare the deinstitutionalization of psychiatric patients and the developmentally disabled in the United States and demonstrate that there were two path-dependent processes with significant qualitative and quantitative differences, ultimately leading to better outcomes for developmentally disabled individuals.

Using secondary literature, we construct a sustained comparison of the two processes in terms of outcomes, timing, tempo, extent, funding, demographic composition, and investment in community services. We then reconstruct the strategies of de-stigmatization and framings of moral worth deployed in the two cases, analyzing their effects on deinstitutionalization in terms of conceptions of risk, rights, and care.

Deinstitutionalization began later for developmentally disabled individuals than for psychiatric patients, and was a more gradual, protracted process. It was not driven by fiscal conservatism, discharges, and the trans-institutionalization of the senile aged, as was deinstitutionalization for psychiatric patients, but primarily by the prevention of institutionalization of young children, and increased investment in infrastructure. Consequently, the deinstitutionalization of the developmentally disabled was far more thorough and successful. The process was shaped by the framing of the developmentally disabled as “forever children” by parents’ organizations that demanded a balance between autonomy, protection, and the provision of care. In contrast, the deinstitutionalization of psychiatric patients was shaped by their framing as autonomous citizens temporarily suffering from “mental health problems” that could be prevented, treated, and cured. This frame foregrounded the right to choose (and also refuse) treatment, while undervaluing the provision of care.

The effects of distress and social networks on psychiatric help seeking were examined in an adult sample from a community survey of 3,481 adults in Baltimore, Maryland. Data were derived from the Johns Hopkins University site of the NIMH Epidemiologic Catchment Area program. Statistical adjustment for the independent effects of social (age, education, marital status, race, household composition, and sex), economic (employment, income, and insurance), and physical health factors were controlled for in estimating the relative odds of mental health service utilization. Subjects who were young, without full-time employment, or who reported one or more chronic medical problems were more likely to utilize mental health professionals. Married persons and the aging were less likely to seek psychiatric treatment. Social support and psychological distress interact to affect the use of mental health care. Persons with weak family ties were five times more likely to seek professional help than those with strong family ties, while persons with confiding social support were over four times as likely to use mental health services as those lacking confiding relationships. Interventions and other treatment efforts to encourage use of mental health services are recommended.

This paper presents a theoretical framework and pilot study that examines the social context of the mental health treatment system and its impact on the spread of HIV among people with serious mental disorders. Recent epidemiological evidence indicates that mental illness clients may be at especially high risk of contracting HIV/AIDS. Mental health professionals' efforts to respond to the emerging epidemic, however, have been limited and focused primarily on individual-level interventions to change risk behavior. Virtually no consideration has been given to how treatment environments influence client risk behavior and/or the effectiveness of HIV prevention efforts. The perspective outlined in this paper builds on existing clinical research and proposes a general sociological framework for researching mental illness clients' HIV risk that emphasizes the clinical sexual culture of treatment programs. In an effort to develop preliminary measures and test key assumptions of the proposed framework, a small pilot study was conducted at a large state psychiatric hospital in the Midwest. The results suggest that clinical sexual culture does have a significant impact on the way both the patients and staff think about the management of patient sexual expression and HIV/AIDS at the hospital. More generally, the findings provide preliminary support for the theoretical framework presented.