Institutionalization and Deinstitutionalization
Even if doctors of prior generations had understood the essentially biological nature of schizophrenia, it is unclear that they would have had much to offer patients in the way of effective therapy beyond the segregation and physical restraints that characterized institutionalization prior to the advent of the modern pharmaceutical industry. In the Middle Ages, mentally ill people were integrated into society and labeled as holy fools or just fools - these individuals were tolerated with amusement. Segregation and institutionalization was reserved for those with leprosy. In the 17th century, however, as leprosy waned in Europe, the stigma attached to leprosy apparently transferred to mental illness, and people with schizophrenia gradually became seen as a menace to society. As a result, they were socially and physically excluded from society in the first insane asylums, or maintained by families who would have largely regarded them as social embarrassments. Thus, the cultural climate concerning madness changed from one of amusement or disinterest to one of fear. This history is documented in author Michele Foucault's book, "Madness and Civilization". The tradition of institutionalizing schizophrenic people has persisted in developed countries ever since.
Hospitals such as Bethlem Royal (popularly known as 'Bedlam') and Bellevue became known for their specialization in and care for the mentally ill; they were early psychiatric facilities. Patient conditions in these institutions were poor, however. The physical treatments hospital staff employed to control patients would be considered abusive by today's standards. Patients were placed in strait-jackets, neglected, isolated from other people, or forced to endure primitive electroshock therapy, insulin coma or (in some cases) lobotomy.
Popularized by Walter Freeman, an American neurologist of the early twentieth century, lobotomy involved the surgical destruction of the frontal cortex of patients' brains. Lobotomy had the effect of calming many previously agitated patients, but it accomplished this feat by destroying the very part of patients' brains responsible for judgment, emotional control, and personality. It was not a humane procedure, and thankfully it was largely discontinued and discredited by mid-century as more effective drug therapies and refined shock therapies became available.
Mental healthcare experienced a revolution at the mid-point of the twentieth century with the availability of the first anti-psychotic medications. For the first time, schizophrenic patients could experience partial symptom relief rather than simply being restrained or tranquilized. In this heady environment, a social movement came into being with the goal of deinstitutionalizing the mentally ill. This movement found expression in critical state and federal supreme court decisions supporting patient rights. Numerous state hospitals were shut down as a result, and previously institutionalized patients were released to live in society with the assistance of the newly created community mental health centers (CMHCs) built in most communities as a result of the 1963 US Federal Community Mental Health Centers Construction Act. The CMHCs continue to be the dominant source of front line care for most schizophrenic patients in America today. Only the most severely disabled patients are maintained in state institutions anymore.
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This would be a happy note to end on save for the fact that the initially adequate funding for the CMHCs has eroded over the years to the point where many struggle to simply provide minimal critical services. The noble goals of deinstitutionalization have been largely accomplished, but the follow through has not been well supported; a condition we hope is remedied in coming years, but which seems unlikely to occur any time soon.
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