Social implications of deinstitutionalization

Jiiumol (I/ Conmiuni:y Rrvrholugv. IPUO. 8. 314-322.

SOCIAL IMPLICATIONS OF DEINSTITUTIONALIZATON* PHIL BROWN

Brown University

Attacks on custodialism offered the hope of more humane treatment approaches. Mental health planners thought that the costs of state hospital care could be reduced by discharging patients into the community. For state governments, this involved a shift of costs and responsibility to the federal government. This shift was accompanied by an increase in cost-effective planning at both state and federal levels. Cost-effective planning uses corporate-style standardization techniques to provide precise, measured types of treatment to certain categories of patients. Such planning is primarily oriented to balanced ledgers of the government budget, rather than meeting specific human needs. The shift in costs also increases profits in the private sector. This is most noticeable in the nursing and boarding home industry where entrepreneurs derive large returns from a new custodialism mainly funded by government reimbursements. The in- stitutional overuse of psychiatric drugs is continued in community programs. Cost- effective approaches also involve firing mental health staff and increasing the workload of those remaining. Community mental health centers and state hospital deinstitutionalization programs have largely failed to meet most of their promists such as noninstitutional treatment, more humane care, prevention, and rehabilitation. These failures have produced the beginning of a delegitimation of the new mental health approaches. This delegitimation is also used as part of more general attacks on social serviced so prevalent in this pcriod of economic crisis. This reinforces the reliance on cost-effective plans which do not benefit clients. It also poses the danger of increasing the number of persons classified as psychological misfits among the marginal underclass. Even though this is an unintended effect, it can then be used to deflect onto these victims popular redent- mcnt against big business and the government. Further, the growth of such a misfit group, along with other types of social decay. may prompt an increase in the already growing forms of social control psychotechnology such as psychosurgery.

Recent criticism of mental health policy and treatment from the federal government, state and local governments, patients rights groups, trade unions, and the media have challenged many aspects and promises of the post-World War I1 “mental health revolution.” Unlike previous criticisms, these come from an extremely wide range of sources, and concern themselves with policies that are still unfolding. Further, unlike earlier exposes of psychiatry, the current ones may function to curtail rather than expand services.

BASIC PROBLEMS IN MENTAL HEALTH POLICY The poor performance in both community mental health programs and

deinstitutionalization has undermined the credibility of those concepts. Brown (1978) discussed how community mental health centers (CMHCs) have not provided community-based, community-controlled preventive and rehabilitative services on a sufficient scale. The CMHCs have extended into many nonpsychiatric areas of neighborhood life, and have increased professional and governmental power. They have not ended the two-class system of mental health care, as was promised. They have not worked together with the state hospitals for their catchment area in admissions, referrals, and discharges (General Accounting Office, 1974).

‘The author would like to thank Ronnie Littenberg for her helpful comments on this article. Send reprint requests to author, Sociology Department, Brown University, Providence, RI 02912.

3 14

SOCIAL IMPLICATIONS 315

State hospitals have not done their part in coordinating services. Massive, unplanned discharges without adequate follow-up has led to large numbers of uncoor- dinated nursing home placements, where people live in unhealthy, dangerous conditions. State mental health departments give up responsibility for patients, and federal funds pick up the major share of costs for deinstitutionalized patients via Medicare, Medicaid, and Social Security's SSI program. Simultaneously, CMHCs have not fulfilled their promise of providing noninstitutional care for many of these patients (U.S. Senate Sub- committee on Long-Term Care, 1976).

Even while overall inpatient population had declined, state hospital admissions and readmissions have climbed substantially, producing a revolving door situation. Figure 1 shows that admissions more than doubled from 1955 to 1969 while the total inpatient population fell by about 309b. Psychiatric drugs, already overused in state hospitals, are being widely employed in nursing homes and in CMHC outpatient and inpatient treatment (General Accounting Office, 1977; President's Commission on Mental Health, 1977). In trying to end the custodialism of the past, and implement the new deinstitutionalization policy, state mental health departments have followed the direction of PL 88-164 and NIMH policies in reducing funds to improve state hospital conditions. Yet community programs have failed to take up the burden of the underfunded hospitals, and the two approaches remain isolated from each other (Okin, 1978).

ROURE 1

Numb* of Rudnt Patime at md d V w md TOW A*ni*ia& hn W CounN I*nW HOwtd& h o d 8- (SO-1974

600 , 1 1 , 1 1 , , 1 1 ) , 1 1 ) 1 1 1 1 , 1 1 1

Source: National Institute of Mental Health, (1976).

When such criticisms are made by the President's Commission on Mental Health (1977) and the U.S. Congress's General Accounting Office (1974; 1977). it bccomes clear that the highest levels of government are extremely concerned about the community

316 PHIL BROWN

mental health/deinstitutionalization policy that not so long ago had been one of the nation’s most touted human services ventures (Sharfstein, 1978).

The many problems of deinstitutionalization have led to significant public and governmental distrust (Borus, 1978). This distrust easily turns to questioning the original concepts, This questioning in a general context of doubt has yielded a cutback in human services, while military expenses have been increased. For instance, the 1981 health services budget sent to Congress by the Carter administration represented a 3.2% cut over 1980, taking into account inflation. For the Alcohol, Drug Abuse, and Mental Health Administration, the budget was down 5% (Kleiman, 1980). The military budget called for a 3% increase over inflation “Carter’s budget,” 1980). On June 9, President Carter signed into law a bill reducing Social Security disability benefits for new recipients by 14% (Zuckerman, 1980). The anti-social-service attitude of the new right found harmony with the mainstream attempts to streamline social programs. California’s Proposition I3 posed a general attack on human services. Across the nation right wing groups have allied with legislators and state executives to produce sharp cuts in spending for higher education, welfare programs, and abortion. Federal mental health spending, under con- stant attack during the Nixon and Ford administrations, now faces the President’s Com- mission on Mental Health which seeks to reorganize mental health services based on a recirculation of the same funds to do more tasks.

CORPORATE REORGANIZATION IN THE SOCIAL SERVICES

Federal and state governments, prodded by their own needs and those of the business interests, are reorganizing social services, putting them on a businesslike footing to cut costs and improve efficiency. But there is little place in such a plan for the human needs of clients. The government cannot simply stop existing social services, but it can redefine needs and how those needs will be met. It can also claim a lack of funds, due to inflation, workers’ demands for wage increases to cope with inflation, unequal trade balances, and other economic difficulties.

Recent budget cuts threaten to reverse decades of mental health planning and expansion. According to one ex-mental health commissioner (Farabee & Press, 1977), some hospitals which have only recently reached per diem expenditures and stalling ratios to meet accreditation standards, will lose that accreditation due to budget cuts. That loss would then lead to a cutoff of public funds, thus perpetuating the cycle.

By standardizing and centralizing human services, government agencies can have better cost accounting over longer periods of time. Precise definitions of acceptable services prevent the expansion of existing programs, even if clients need expanded services. Planners can exert more control over staff and clients. Ultimately, clients may even avoid using services that are bureaucratic, impersonal, and somewhat inaccessible. Mental health planners increasingly speak of using standardized symptom checklists to produce routine diagnoses and treatment plans (Ozarin, 1975). This would prevent those providers truly interested in relevant, personal service from exceeding established standard services. Such an approach could have little therapeutic benefit for the client if it withholds the very central interpersonal relationship which is so necessary for psychiatric treatment.

Patry (1978) examined the Texas Department of Human Resources (welfare department ) in a two-year contract study following a 1977 budget reduction. The study sought to standardize and increase the workloads of welfare workers while at the same time decreasing the number of staff. Both clerical and interpersonal work tasks were standardized, and “case characteristics’’ of each client were determined. The correlation of each


characteristic and its processing time was determined, and clients were classified into different groups based on processing time. The number of clients in each classification were counted and the number of caseworkers needed was determined solely on the basis of time.

Job hierarchies were created and strengthened to separate the conception of work from actual performance. Patry noted that the full implementation of the plan would en- tail having clerks perform some of the tasks previously carried out by social workers. In the state’s view, this would decrease the need for professionally trained social workers. With such a model, Patry wrote, “The fact that the input is a real human being with real and possibly complex needs is irrelevant.” While it is obviously difficult to quantify the quality of psychiatric treatment under such standardized methods, psychotherapists’ and social workers’ general sensibilities could be expected to rebel at this level of technologized and depersonalized services.

The health maintenance organization (HMO) is a model central to planning for a nationally coordinated, cost-effective system. Although private practitioners and smaller community hospitals typically oppose HMOs, large medical complexes centered around university medical schools usually favor them. So do important sectors of the corporate world and the federal government.

Paul M. Elwood. a medical advisor to ex-President Nixon, designed a federally sub- sidized, corporate HMO prototype which he urged transnational corporations to adopt in the interest of greater efficiency and cost reductions (Salmon, 1977).

Since the medical establishment is increasingly controlling the mental health system, the HMO model is taking on psychiatric coverage. Mental health planners have favorably cited the fact that brief psychotherapy of two to eight sessions in an HMO reduced medical utilization of those patients by 75% within the five subsequent years (Mental Health Association, 1977). This fits with the general HMO strategy of con- taining costs by limiting visits and using many nonphysicians in primary care. Limiting visits to so few sessions may remove some symptoms, but may not deal with underlying causes. There is debate on the effectiveness of short-term therapy, but it would be more appropriate to decide that issue on therapeutic grounds rather than on administrative and economic criteria. Further, while HMO utilization of nonphysicians may open the door to psychologists, they may find themselves working under the close scrutiny of psy- chiatrists or other physicians who prefer an organic model to a psychological approach.

A further problem is that if corporations run their own HMOs, as the federal government is urging (Salmon, 1977). they will not only save money on costly health insurance premiums, but could exert much control over their employees. By defining the legitimacy of illness, both on and off the job, companies can have more control over absenteeism and worker organizing. They can also redefine occupational health and safety issues by claiming that job injuries were personal injuries. This basic corporate policy can be seen in the coal industry, where coal companies contribute to miners’ clinics. To avoid responsibility in the nation’s most dangerous industry, coal operators contend that the terrible black lung disease is really emphysema, brought on by tobacco smoking.

The Professional Standards Review Organization (PSRO) is another form of standardization of practice that is being widely discussed in mental health circles. Officials of The National Institute of Mental Health (NIMH) believe that PSROs will play a major planning and evaluation role in any mental health coverage under a national health insurance plan. They see the PSRO as curtailing hospital admissions and as making a “more economical use of staff’ (Ozarin, 1975). Standardized checklists of symptoms will

’

318 PHIL BROWN

be used to determine length of stay and type of treatment. Even some proponents fear that such centralized record keeping is a threat to confidentiality (Cohen, Conwell, Ozarin, & Ochberg, 1975; Goldstein & Cohen, 1975; Ozarin, 1975). This model bears much resemblance to that described by Patry.

Plans by commercial insurers and Blue Cross are also related to the gearing up for national health insurance. Insurers believe that they can emulate the HMOs’ reductions in medical visits by providing brief outpatient psychiatric coverage. Twelve states now require such coverage in all health insurance. NIMH (1976) has been particularly interested in arguing this case to the insurance industry and the federal health planning bodies.

All these forms of corporate reorganization are on the rise. In terms of outpatient therapy, CMHC inpatient and outpatient treatment, and treatment in psychiatric hospitals and general hospital psychiatric wards this reorganization has not yet delivered the promised cost savings (Kirk & Therrien, 1975; President’s Commission on Mental Health, 1978). Nor will it provide humane therapeutic and rehabilitative treatment. Cor- porate style reorganization of social services usually involves lay-offs, hiring freezes, and increased burdens for remaining staff. A false professionalism is created by providing new job titles, a facade of more responsibility, and a clearly defined hierarchy. Union leaders claim that instead of opposing these harmful plans, staff (particularly when not unionized) tend to vent their anger and frustration on subordinates and clients (Rasmussen, Note I ) .

THE NEW CUSTODIALISM Parallel to attempts at a business-type reorganization, many critics have focused on

the development of a new custodialism in the growth of nursing and boarding homes. These homes have become the primary form of mental health treatment, as well as the major expense. Approximately 900,000 mentally disabled persons (of all types) live in these homes, which in 1974 accounted for over 94% billion, or nearly 30% of total United States direct mental health costs (U.S. Senate Subcommittee on Long-Term Care, 1976). Unplanned transfer of chronic state hospital patients has led to an enormous growth in these homes. In many cases, the conditions in the homes rival those of the custodial asylums which were so strongly criticized by mental health planners not so long ago.

The homes are virtually all private, profit-making concerns, many of which have been created to take advantage of the federal funds which are being used to pay for the ex-patients. Medicaid, Medicare, and SSI programs, originally designed to assist poor, elderly, and disabled persons obtain medical care and life support services, have become windfall profit catalysts for unscrupulous nursing home operators (U.S. Senate Subcom- mittee on Long-Term Care, 1976). The increase of nursing and boarding homes seems to be continuing. The question of whether to use nursing homes for mental health care may have passed out of the hands of the mental health policy makers and into the hands of the human services profiteers.

The widespread use of psychiatric drugs is part of the New Custodialism. Just as psychiatric drugs have been integral to the maintenance of state hospital patients, so too are they standard for ex-patients. The chaotic deinstitutionalization process has relied on heavy dosages of psychiatric drugs because patients were maintained on those dosages prior to release, and since no one seems to expect that the homes will provide enough staff, or a significant level of therapy and rehabilitation. The dangerous side effects of


psychiatric drugs have unfortunately been ignored and/or misunderstood (Asnis, Leopold, Duvoisin, & Schwartz, 1977; Gunderson, 1977).

EXPANDING THE PSYCHOSOCIAL MISFIT STRATUM I N THE MARGINAL UNDERCLASS The growing admission and readmission rates to state hospitals, the increase in

CMHC inpatient utilization, the central position of the custodial nursing homes, and the rise in drug dependence and disease lead to the conclusion that there may be a new stratum of psychosocial misfits being created within the marginal underclass. There is always a surplus population in capitalistic societies and this marginally or rarely employed group appears to be increasing. Psychiatric patients may be making up a growing segment of the underclass. As Brenner (1973) has shown, mental hospital admission rates increase with unemployment. The prognosis, therefore, is bad. From 1950 to 1974, unemployment never exceeded 696, and was under 5% most of those years. In 1975, it hit 8 . 5 8 , followed by 7.7% in 1976 and 7% in 1977. The rate has remained above 6% since 1978, and it is expected to rise once again to 8.5% (“Dollars & Sense,” 1978; “The Economy,” 1980). It seems reasonable to surmise that this unemployment problem has some effect on the growth and status of psychiatric ghettos in our large cities.

One implication is that these people, presently supported largely by state and federal welfare funds, will be defined as additional “welfare chiselers” who should be cut off from the public purse. Such a classification provides a legitimate reason for decreasing or ending support from the point of view of politicians and organizations that are against welfare, but would have a difficult time reducing a mental health budget line.

Another implication is that regular members of the work force may enter mental health services much more rapidly than in the past. This would be due to the expansion of the mental health establishment into many areas of life previously not part of the mental health system. The use of mental health professionals in job-counseling situations, for ex- ample, could serve to label a person as being prone to unemployment due to personality disorder rather than to economic disorder. Such a perspective was suggested by a short videotape, “Critical Mass Gallery,” produced several years ago at Elgin State Hospital in Illinois.

SOCIAL CONTROL ASPECTS Neither community mental health centers nor state hospital phaseouts have altered

the two-class system of mental health care. The two-class system, as criticized by the Joint Commission on Mental Illness and Health (1961), provided state hospital maintenance for poor and working class people, and private hospitalization and outpatient treatment for the middle and upper classes. Mental health professionals have long been criticized for their class biases in conceptions of mental illness (Davis, 1938). The class bias in prevalence, diagnosis, and treatment, found in the 1950s by Hollingshead and Redlich (1958), still holds true. To the extent that the mental health system duplicates the inequalities of the entire society, it serves a social control function. This is brought into sharper focus by looking at the interface of class bias and racism. Black people are making up larger percentages of state hospital populations, even at a time when state hospitals are being phased out and depopulated. But Black people are making up smaller percentages of the patient population in private psychiatric hospitals, and psychiatric wards of general hospitals (both public and private) (Faden, 1977; Meyer, 1974. 1977).

More alarming is the source of state hospital admissions. Black persons are increasingly being sentenced to mental hospitals by the courts for incompetency to stand

320 PHIL BROWN

trial. As Table I shows, the percentage of Black people so admitted equals 6.9% of all black admissions in 1972, five-and-a-half times the white percentage. This raises the danger of the declining state hospitals being used for a largely minority population who could be denied consideration for community programs which the mental health establishment considers better psychiatric care.

TABLE 1 Legal Status of Admission to State and County Mental Hospitals by Race,

1972-Pe~ent Disiribution by Legal Status

Legal status Race

Total Total White Nonwhite

Total 100% 100% 100% Voluntary 48.6 51.8 35.4 Nonprotesting 5.7 5.0 8.6 Involuntary 41.8 40.5 47.4 Prison Transfers 1.5 1.5 1.2 Incompetent to Stand Trial 2.3 1.2 6.9

Source: Bachrach, 1975. Note: The category “total white” includes Spanish-Americans. In its original form, this table

included a category of “Spanish-American” and ”Other white,” although many tables from NIMH do not provide that categorization.

Related to this is the growth in the psychiatric system’s service of the police-prison- court apparatus in combination prison-psychiatric institutions, such as California’s Vacaville, Maryland’s Pautuxent, Massachusetts’ Bridgewater, New York’s Dannemora, and the federal government’s facilities in Marion, Illinois, and Butner, North Carolina. These facilities have pioneered in the use of new psychotechnology-behavior modification, aversion therapy, and psychosurgery for activist prisoners, homosexuals, and others (Chavkin, 1978). The revival of psychosurgery in the last decade has also focused on “promiscuity” in women and “hyperactivity” in children (Roberts, 1972).

Psychiatrist Peter Breggin (Note 2) was the first to note publicly the revival of psychosurgery, after its slip into obscurity in the 1950s. Federal interest in psychosurgery, especially in the Justice Department and NIMH, was largely based on fear of black ghet- to uprisings in the late 1960s. and prisons were among the new centers of psychosurgery and related psychotechnology. Psychosurgery has effectively reentered the psychiatric mainstream, and in 1977, the Department of Health, Education, and Welfare gave a blanket approval to the procedure as valid and therapeutic (Brown, 1977; Chavkin, 1978).

Psychosurgery, electronic stimulation of the brain, and aversion conditioning are desirable to some in the mental health system, and to many of their supporters in other areas. Not only do such techniques promise control over social misfits, but they also make possible less costly and noninstitutional maintenance. As political affairs turn more to the right. such approaches may receive even more support than in their heretofore isolated efforts.

SOCIAL IMPLICATIONS 32 1

CONCLUSION This article has argued that the lack of success in community mental health and

deinstitutionalization has important social implications which go far beyond the mental health field. The failures in mental health poliq' have enabled the conservative government to reduce support for large-scale psychiatric services. The federal and state governments have cut back on mental health programs and have pursued corporate style standardization. Such reorganization has little effect, however, on the largely unplanned discharge of thousands of state hospital patients. These patients are sources of profit for the growing federally supported nursing home industry and for all industries involved in supplying the homes. The numerous expatients in urban "psychiatric ghettoes,' are an expansion of a psychosocial misfit stratum of the marginal underclass. The increase in that stratum, along with general social decay, may lead to further use of social control techniques.

In order to prevent worse possible outcomes of flawed mental health policy, a thorough revaluation is necessary. The chaotic mental health establishment, with dozens of agencies at the state and federal level, must be welded into a more harmonious structure, without sacrificing the overall funding. As should be obvious, massive increases in mental health funding are needed, and false cries of military preparedness should not be accepted as a reason for putting off mental health funding.

The new funds must be spent differently than in the past. Strong legislation is necessary to curtail the enormous profits of the nursing and boarding homes. Ultimately the best solution would be for state agencies to run community placements, a relatively rare phenomenon to date, but one which is increasingly receiving support of critics of deinstitutionalization (Rasmussen, Note 1). Legislation is also necessary to remove the senseless restrictions on third-party reimbursements which have played such an important role in the growth of the homes industry. Funds are also needed to retrain state hospital workers and to train new staff for the community programs.

Without these minimum changes, the present chaos of deinstitutionalization will most likely continue to worsen. And given the situation at present, this is simply not tolerable for either the clients or the providers.

REFERENCE NOTES I . RASMUSSEN, B. Deinstitutionalization from the employees' perspective. Paper delivered at District I 199

Conference on Deinstitutionalization, University of Connecticut-Farmington Medical Center. October 20. 1979.

2. BKEGGIN, P. Statement in Congressional Record, March 30, 1972.

REFERENCES ASNIS, G. M., LEOPOLI), M. A., DUVOISIN, R. C., & SCHWARTZ. A. H. A survey of tardive dyskinesia in psy-

chiatric outpatients. American Journal of Psychiatry. 1977, 134, 1367-1370. BACHKACH, L. Utilization of state and county mental hospitals by Spanish Americans in 1972. National

Institute of Mental Health Statistical Note No. 116. Rockvillc, Md.: National Institute of Mental Health, 1975.

BOHUS. J. Issues critical to the survival of community mental health. American Journalof Psychiatry. 1978,

BKENNtK, M. H. BHOWN. P. Protests hit government approval of lobotomies. Guardian, April 27, 1977. BROWN, P. Political-economic and professonalistic barriers to community control of mental health services:

/35, 1029-1035. Mental illness and the economy. Cambridge, MA: Harvard University Press, 1973.

A commentary on Nassi. Journal of Community Psychology, 1978, 6, 381-392.

322 PHIL BROWN

Carter's budget-Bombs away, stalemate at home, Dollars & Sense, March, 1980, pp. 3-5. CtiAvKiN. S. COitEN. G. D., CONWELL, M.. OZARIN. L. & OCHBERG, F. PSROs: Problems and potentials for psychiatry.

DAVIS, K. Mental hygiene and the class structure. Psychiatry, 1938. I , 55-65. A Dollars & Sense reader. Somerville, MA: Economic Affairs Bureau, 1978, 16-17. The economy in numbers, Dollars & Sense, March, 1980. p. 10. FADEN, V. B. Differential utilization of non-fedeml general hospital psychiatric inpatient units, by

race-United States 1974-1975. National Institute of Mental Health Statistical Note No. 134. Rockville, Md.: National Institute of Mental Health, 1977.

FAHABEE, D. H.. & PRESS, L. Legislative perspective on mental health programs. State Government. Autumn, 1977. pp. 203-208.

GENEHAI. ACCOUNTING OFFICE. Need for more efective management of community mental health centers program. Washington. D.C.: US. Government Printing Office, 1974.

GENEHAI. ACCOUNTING OFFICE. Returning the mentally disabled to the community: Government needs to do more. Washington, D.C.: US. Government Printing Office, 1977.

GOI.I)STtlN. H. H.. & COHEN. G. D. CMHCs and PSROs: The emerging interface. Administration in Men- tal Health. Spring, 1975. pp. 12-18.

GUNI)~HSON, J. G. Drugs and psychosocial treatment of schizophrenia revisited. Journal of Continuing Education in Psychiatry. December. 1977. pp. 25-40.

HOI.I.IN~iSIItAI>. A. B., & REDLICH, F. C. Social class and mental illness. New York: Wiley, 1958. JOINT COMMISSION ON MENTAL ILLNESS AND HEALTH. Action for mental health: Final report of the Joint

KIRK, S. A., & THERRIEN, M. E. Community mental health myths and the fate of former hospitalized mental

KLEIMAN. M. The 1981 health budget. HealthIPAC Bulletin, May-June. 1980. pp. 23-31. MENTAL HEALTH ASSOCIATION. A plan of coverage for the mentally ill in national health insurance.

Arlington, Va.: Mental Health Association, 1977. MEYER, N. Age. sex, and color variations in the diagnostic distribution of admissions to inpatient services of

state and county mental hospitals. United States, 1972. National Institute of Mental Health Statistical Note No. I1 1. Rockville, Md.: National Institute of Mental Health, 1974.

MEYER. N. Diagnostic distribution of admissions to inpatient services of state and county mental hospitals. United Stares, 1975. National Institute of Mental Health Statistical Note No. 138. Rackville. Md.: National Institute of Mental Health, 1977.

NATIONAL INSTITUTE OF MENTAL HEALTH. The financing. utilization, and quality of mental health care in the United States. Rockville, Md.: National Institute of Mental Health. 1976.

OKIN, R. The future of state mental health programs for the chronic psychiatric patient in the community. American Journal of Psychiatry, 1978, 135. 1355-1358.

OZARIN, L. D. PSROs and mental hospitals: A report. Administration in Mental Health, Spring, 1975, pp.

PATRY. B. Taylorism comes to the social services. Monthly Review, 1978, 30, 30-37. PRESIDENT'S COMMISSION ON MENTAL HEALTH. Report to the President. Vol. I . Washington. D.C.: U.S.

ROBERTS, B. Psychosurgery. The final solution to the woman problem. The Second Wave, 1972. 2, 3-8. SALMON. J. W. Monopoly capital and the reorganization of the health sector. Review of RadicaI Political

SHARFSTEIN, S. Will community mental health survive the 198Os? AmericanJournaI ofPsychiatry. 1978,135,

U.S. SENATE SUBCOMMITTEE ON LONG-TERM CARE OF THE AGING. The role ofnursing homes in caring for discharged mentalpatients (and the birth of a for-projt boading home industry). Supporting Paper No. 7 of series "Nursing Home Care in the United States and Failure in Public Policy," Washington, D.C.: U.S. Government Printing Office, 1976.

The mind stealers: Psychosurgery and mind control. Boston: Houghton-MiWin, 1978.

American Journal of Psychiatry, 1974, 131, 1378-1381.

Commission on Mental Illness and Health. New York: Basic Books, 1961.

patients. Psychiatry, 1975, 38, 209-217.

19-22.

Government Printing Office. 1978.

Economics, 1977, 9, 125-133.

1363-1365.

ZUCKERMAN. S. Congress cuts disabled budget. Guardian, June 25, 1980, p. 3.

Social implications of deinstitutionalization

Documents

Transcript of Social implications of deinstitutionalization