From the Book, Chapter 4
In this final chapter, we will look first at how deinstitutionalization, the rise of the case manager, and community support services have evolved. We will show how they follow from and require one another. We will then consider how the relational method proposed in this book relates to this history. For fifty years, the prevailing policy for care of the mentally ill in the United States has been deinstitutionalization.
Today, for most, the large state mental hospitals are a distant memory and mostly the subject of historical study. However, in 1975, when One Flew Over the Cuckoo’s Nest (an Oscar-winning film, starring Jack Nicholson, depicting the lives of the mentally ill in the “total institution”) appeared, it was for many, struggling to adapt and survive in communities, an all-too-present reality. Today, former hospital
“patients” (our clients or consumers) must live, eat, travel, work, play, and seek help in a radically decentralized and often imagined institution called the community. And in the transition from hospital to community, a new mental health practitioner was invented: the case manager. Along with the case manager and case management, entirely new practices and vocabularies emerged. These practices, often invented in the moment of working with consumers, have over time been organized into models such as strengths and assertive community treatment (Angell et al., 2006;Floersch, 2002). What is consistent across the many mental health practice models is the presence of the new practitioner called the case manager. Indeed, the idea and history of deinstitutionalization and the history and idea of management go together; they need one another (Mowbray and Holter, 2002:139–142). Inside the “total institution,” management was not the concern.2 Inside the large, bureaucratic state hospitals, the mentally ill were subject to highly rationalized forms of control and surveillance. In hospitals, the object was to control and to treat, not to manage need and desire. In short, there were patients, not cases. There was treatment, not management.
Daily needs (e.g., food, housing, healthcare) were not only provided, they were required (Grob, 1995). Moreover, hospitals were restricted environments. What do we mean by “restricted environments”? First, one could not freely circulate inside the hospital. You were not just confined to the hospital, a specific ward, a locked room, or the surrounding grounds. You were also under the constant, watchful eye of the nurse or orderly. Michel Foucault (2006), a French philosopher and social theorist, called this the medical or psychiatric gaze, or panopticon. In the panopticon, you were watched and monitored from a central observing point, such as the nurse’s station or prison watchtower. Your movements and location were monitored in the interest of your treatment. Second, you were not free to work or earn an income. Third, moment to moment, your life was routinized: bedtime, mealtime, therapy, exercise, leisure. One could and often did live a lifetime in the hospital, abandoned by family and buried on hospital grounds. Eventually, critics and social reformers saw these environments as warehouses, as places of horrific human experimentation, where human dignity and freedom were entirely compromised.
In sum, in the absence of the total control offered by the total institution (e.g., hospitals, prisons, schools), one needed management. And management was to take place in communities, where shelter, housing, and other basic needs had to be met through existing social safety nets (Medicaid, Medicare, Social Security, other entitlement programs, county and city government, charities, and family) and the market. With the decline of the large public hospital, case managers replaced doctors and nurses in the daily lives of those with severe and persistent mental illness.
Looking back over the half-century since the beginning of deinstitutionalization, we can see a tendency to rigidly oppose institutional care with care in the community. However, care in the community did not eliminate institutions, nor did it occur seamlessly, nor without its own, perhaps more subtle forms of control, surveillance, and inhumanity: homelessness, overmedication, poverty, and warehousing in jails (Abramsky and Fellner, 2003; Angell et al., 2006). It seems that less visible walls, called catchment areas, replaced hospitals and locked wards. Indeed, many have argued that the movement has been a dismal failure (Fuller-Torrey and Miller, 2002), nor were the barriers produced by social stigma removed (Hinshaw, 2007). Emptying mental hospitals presented numerous and tough challenges to former patients like Marilyn. Her needs were many: housing, education, employment, medication, meaningful relationships, and mental health and social services. For Marilyn life in the community required constant movement in and out of community institutions: mental health centers, partial hospitalization programs, supportive employment, community college, family. And her case managers were at the center of this unending psychological and physical circulation (Floersch, 2002). Although many like Marilyn lived in their own apartments and homes in neighborhoods, they also, like Marilyn, rotated in and out of intermediate care and residential care facilities: nursing homes, jails, shelters, and transitional living apartments. Indeed, a whole new set of institutions and problems developed around the so-called deinstitutionalized patient (Torrey, 2002). And in this way one might argue that deinstitutionalization is a myth. Why? We are always in institutions, necessarily so, in a creative and continual tension between strivings for dependency and independence.