How Mass Deinstitutionalization Harmed the Mentally Ill

National News

One year ago Thursday, the horrific school shooting in Parkland, Florida, sparked an intense national debate over firearm-related violence.

As some pushed for broader restrictions on the Second
Amendment rights of law-abiding citizens, The Heritage Foundation has
undertaken the task of evaluating the complex, underlying realities of gun violence,
including its relationship to untreated serious mental illness.

As part of a series of papers exploring this relationship,
John Malcolm and I authored a Heritage Legal Memo, “The
Consequences of Deinstitutionalizing the Severely Mentally Ill
focusing on the mental health crisis in the United States and how states can
combat that crisis to make communities safer.

Our paper begins by exploring several catalysts for the mass
removal of the seriously mentally ill from inpatient facilities during the
1960s and 1970s, a process referred to as deinstitutionalization.

The first catalyst was a growing public awareness of the
truly abysmal conditions in some large state psychiatric hospitals, which
caused some to look for treatment options with more humane conditions.

Second, a general trend in the medical profession toward
promotion of community-based treatment centers coincided with development of
promising psychiatric medications that led many professionals to reconsider the
possibility of successfully managing mental illness outside institutional

Third, the establishment of Medicaid in 1965 de facto
encouraged states to eliminate public psychiatric beds by prohibiting states from
using federal money to pay for adult inpatient psychiatric care and promising
additional money for each patient moved to outpatient care. It was financially
beneficial for states to have as few public psychiatric beds as possible, and
states began altering provision of mental health services to maximize their
receipt of federal dollars.

Finally, beginning in the 1970s, the Supreme Court issued a
series of opinions that made it harder for states to civilly commit even the
most clearly mentally ill individuals, and also made it easier for those
individuals to refuse treatment even when civilly committed.

As a result of these social, medical, and legal changes, the
number of available public psychiatric beds in the U.S.  dropped by 95 percent between 1955 and 2016.

Most policy experts indicate that states need a minimum of 40 to 60 beds per 100,000 people to meet the needs of a population. But in 2016 the average state provided only 11.7 beds per 100,000 people.

States Cut Mental Health Budgets

The dramatic reduction in available beds has been compounded
by equally dramatic reductions in state mental health spending. States cut a
cumulative $4.35 billion from their mental health budgets between 2009 and

Although mass-scale deinstitutionalization began with the best of intentions, society simply did not have adequate community-based alternatives in place—nor have states since created the necessary alternatives.

The results have been devastating for both those with serious mental illness and communities that spent decades struggling to cope with a crisis they were not equipped to handle.

Several studies have found that having fewer psychiatric
beds is associated with higher crime rates, including for violent crimes such
as murder and assault. There are also strong indications that the dramatic rise
in violent crime during the 1980s and 1990s was, in large part, an effect of
deinstitutionalization and the massive influx of individuals with untreated
mental illness back into their communities.

Meanwhile, the equally sudden decline of crime rates in the
1990s and 2000s can be explained in large part by the “reinstitutionalization”
of these individuals into jails and prisons.

The burden of dealing with these individuals with untreated
serious mental illness has fallen increasingly on law enforcement officers
instead of on mental health professionals. This results not only in millions of
lost man hours for law enforcement departments, but also places officers and
mentally ill individuals at greater risk.

Some studies suggest that as many as one-third of all
shootings by law enforcement officers are the result of individuals with mental
illness committing “suicide by cop.” A 2012 analysis estimated that at least
half of all physical attacks on law enforcement officers were by mentally ill
individuals—many of whom were untreated.

To our national shame, many mentally ill individuals are reinstitutionalized into jails and prisons, where they do not receive proper treatment. In fact, America’s jails and prisons have become the nation’s new psychiatric facilities: One recent survey found that between 37 percent and 44 percent of state and federal inmates had been told by a mental health practitioner that they suffered from a mental health disorder.

Not Enough Psychiatric Beds

These mentally ill inmates cost considerably more to
incarcerate, stay incarcerated for longer periods, and are victimized at far
higher rates than are inmates who aren’t mentally ill.

Further, the few public psychiatric beds remaining often are
filled up quickly as “forensic beds” for these mentally ill inmates, while
nonviolent, noncriminal but seriously mentally ill individuals are left to
overcrowded emergency rooms. There, they spend days and sometimes weeks being
stabilized, waiting for inpatient beds to open up and proper long-term
treatment to begin.

This not only disproportionately diverts emergency room
resources to crisis management for psychiatric patients, but helps exacerbate
the mental health crisis by leaving many individuals in need of serious
long-term treatment on waiting lists, allowing them to grow sicker—and in some
cases, violent—before beds open up.

This can have catastrophic results, as shown by the case of
David Logsdon in 2007. Logsdon suffered a mental health crisis but was released
from a Missouri mental hospital after just six hours due to a bed shortage, and
did not receive any more mental health treatment. His condition deteriorated to
the point that he killed a neighbor and used a stolen rifle to shoot people at
random in a mall parking lot, killing two and injuring seven.

States can take practical steps to combat the effects of
deinstitutionalization, including strengthening their civil commitment laws, better
using existing mental health frameworks, and increasing the number of available
public psychiatric beds.

Recent studies have produced strong evidence that when
states make it easier to order those with untreated mental illness to submit to
outpatient or inpatient treatment, they tend to have lower murder rates as a
result. In fact, over 25 percent of all state-to-state variations in murder
rates could be explained solely by differences in civil commitment laws.

Strengthening the ability of law enforcement officers to involuntarily detain an individual suffering from a mental health crisis on an emergency basis realistically could have prevented a significant number of mass public killings.

Enforcing Existing Procedures

Further, enforcement of current mental health mechanisms is
often too lax and allows individuals who are known to be dangerous to
themselves or others to legally access firearms and avoid necessary mental
health treatment.

This, too, has been a primary factor in many otherwise preventable mass public shootings, including the events that occurred Feb. 14, 2018, at Marjory Stoneman Douglas High School in Parkland, Florida. There, law enforcement and school officials had ample evidence that the shooter was in desperate need of court-ordered mental health treatment, but never acted on that evidence in a meaningful way.

States also should reinvest in public psychiatric
facilities, ensuring a sufficient number of beds of last resort to meet the
needs of their citizens. The up-front costs of providing adequate numbers of
public psychiatric beds may seem daunting, but they pale in comparison to the
long-term costs of shifting the burden of housing and treatment to the criminal
justice and emergency medical systems. The human and economic costs associated
with untreated serious mental illness also are tremendous. 

These steps—which focus on serious, underlying problems
instead of on particular means of violence—are more much likely to prevent
future atrocities than the broad imposition of gun control measures on the
general public.

More importantly, these steps have the capacity to change
the lives of those mentally ill Americans who have been left in the crosshairs
of deinstitutionalization and whose illnesses can’t be treated with gun

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