Deinstitutionalization and community care

On this plate (6 sections)

Deinstitutionalization is the policy of closing or shrinking large psychiatric hospitals and replacing them with services in the community, such as outpatient clinics, supported housing and general hospital units. It happened at different speeds in different countries, and almost nobody agrees on a single account of why. This page sets out the main drivers, a few dated milestones from the United States, England and Italy, and the two competing stories about the results.

Why it happened: several pressures at once

Accounts usually list a handful of causes, and they carry different weight depending on who is writing. Critics of institutional life, including the sociologist Erving Goffman (see Asylum reform and its critics), shaped how policymakers and the public saw large hospitals. New medicines mattered too. A Congressional Research Service summary says approval of the first antipsychotic, chlorpromazine, in the 1950s made community treatment seem more feasible, and the 2021 history cited below lists chlorpromazine, reserpine and other new drugs among the reasons psychiatrists felt optimistic. The editors treat medication as one factor among several rather than the single cause.

Money and politics played a part as well. A 2021 history of the American Community Mental Health Act notes that President Kennedy grasped public unease about a growing institutionalized population and its cost to the states. In England, by contrast, Enoch Powell said the community alternative was expected to cost roughly what hospitals did, so savings were not the stated aim. Rights arguments grew stronger over time. In 1999 the US Supreme Court held in Olmstead v. L.C. that unjustified segregation of people with disabilities can violate the Americans with Disabilities Act, and public bodies must provide community services when appropriate.

Key milestones

Selected milestones in three countries

Date	Place	What happened
March 1961	England	Powell's speech to a national mental health conference called for a ten-year program, a 50 percent bed reduction and care in community settings.
1963	United States	The Community Mental Health Act funded three years of grants, totaling $150 million, for 1,500 centers. It passed the Senate 72 to 1 and the House 335 to 18.
1978	Italy	A national reform law, associated with the psychiatrist Franco Basaglia, began a shift toward community-based care.
1988 to 1989	England	The Griffiths Report urged stronger management of community care, followed by the White Paper Caring for People.
1999	United States	Olmstead v. L.C. tied community services to disability rights law.

Powell described the old asylums as "isolated, majestic, imperious," a line still quoted in English histories. Kennedy's message to Congress on February 6, 1963 aimed to cut by half, within a decade or two, the roughly 600,000 people then institutionalized, according to the 2021 history above.

What supporters point to

Italy offers the most complete example of hospital closure. A 2018 review of the law by R. Mezzina reports that all psychiatric hospitals closed over two decades, that the new community system fostered what the author calls the lowest rate of involuntary care, and that the World Health Organization has pointed to Trieste and its region as a practical example of the shift. The same review is candid about limits, noting that the law was applied with few resources and that organizational weaknesses remain.

Evidence on outcomes in other countries is also more reassuring than public debate suggests. A 2016 systematic review of 23 studies that followed long-stay patients after hospital discharge found that homelessness and imprisonment "occurred sporadically," and most studies reported no case of either. The authors concluded that these findings contradict ecological studies that linked fewer psychiatric beds to more homelessness and imprisonment.

What critics say went wrong

The same 2021 history argues that the American Act did not fulfill its promise. Centers varied widely, many focused on people with less serious illness, and most did not offer the basic supports that people with serious mental illness needed to live in the community. Care often fell to families, and some people ended up moving among emergency rooms, jails and prisons. Funding was patchy, and Medicare and Medicaid, created in 1965, were out of reach for many.

This account sits beside the 2016 review above, which found the picture in follow-up studies less alarming. The two do not measure quite the same thing. One looks at policy and the services that were actually built, and the other tracks people who were discharged from long-term hospital care. The disagreement is real, and the editors do not claim to settle it.

Where the debate stands

The Congressional Research Service summary says stakeholders disagree on the right balance between hospital and community services, although most agree that psychiatric bed supply does not meet demand. Some argue for more beds, and others for more community care to prevent crises. Families who carried much of the burden have their own history, told in Family advocacy and the role of carers. People who had lived in hospitals argued for a different kind of community, one they helped run, as described in The consumer/survivor movement. Later international law added a rights framework in The UN Convention on the Rights of Persons with Disabilities, and dated entries appear on the timeline.

The short version

Deinstitutionalization came from critics, new medicines, rising costs and rights arguments working together, and it unfolded differently in the United States, England and Italy. Supporters see lower coercion and a rights-based model. Critics see unmet needs, family strain and, in some accounts, homelessness and incarceration. For decisions about a person's own care or legal position, a clinician or a qualified adviser is the right source, since services and laws differ by place and change over time.