Recovery From Schizophrenia: Psychiatry And Political Economy

92 DEINSTITUTIONALIZATION1960s, in the last two decades of the twentieth century, the US assumed some ofthe teaching role.Why did the deinstitutionalization movement go sour in Britain? Why did itstart out so bitter in the United States and turn sweeter later? Or, phrasing thequestions differently, why was there a golden era of active social and communitypsychiatry in northern Europe in the immediate post-war years but little of notein the United States until the last years of the twentieth century?OUTDOOR RELIEFSociologist Andrew Scull in his book, Decarceration, attributes the motivating forcefor the British and American deinsitutionalization movement to the postwardevelopment of welfare programs that enabled the indigent and the disabled to bemaintained more cheaply outside an institution. 58 This form of support, known tothe Victorians as “outdoor relief,” had been drastically reduced in the midnineteenthcentury. The twentieth-century Great Depression increased thepressure for a more comprehensive relief of poverty in the industrial nations, andboth Britain and America instituted social-insurance schemes for the totally andpermanently disabled in the five years following the Second World War. 59 Scull’sanalysis has considerable merit. Ödegard made a similar observation concerningNorway’snew and improved pension system for persons incapacitated by illness,which was introduced in 1960 and which includes psychotic invalids…This has made possible the discharge of many psychotic invalids and isprobably the main reason why the rates of discharge as ‘not cured’ did notshow any great increase until after 1960. 60It is also clear, as Andrew Scull has argued, that the American switch to the use ofnursing homes was attributable to the health-insurance structure. The stategovernments are responsible for the cost of maintaining patients in state mentalhospitals, but care provided in a private nursing home may be billed to Medicaid(for the indigent) or Medicare (for the elderly and some indigent). Since thefederal government pays a large part of these insurance bills, it rapidly becameapparent to state legislators after the inception of these programs in 1965 that theycould cut the state budget by transferring mental patients to private-sector care.Reference to disability pensions and health-insurance schemes, however, doesnot answer all the questions about the early stages of deinstitutionalization.Looking at disability payments, one would have predicted, for example, a lateonset for community care in Norway, and an earlier, roughly simultaneous timingin Britain and America. To understand why the post-war social psychiatryrevolution took place in northern Europe and not America, and why itsubsequently stagnated in Britain, it is necessary to study other political factors.