“Perhaps in [Alinsky’s] view, the social work profession talked a good game, but when the going got tough, social work practitioners could always retreat into agency-based practice and into an emphasis on middle-class professionalism.”
-Fisher, R. & Karger, H.J. (1997).
Beginning in the 1970s, deinstitutionalization was conceptualized as the swiftly implemented movement of institutionalized patients from large, state-run asylums to Community Mental Health Centers (CMHC). The movement also included the prevention of long-term institutional care with the accretion of CMHCs (Morell, 1979). Revisiting deinstitutionalization creates space to unpack the enduring tension within the field of social work between micro-level practice and macro-level advocacy.
To that end, I first explore the policy formation that laid the foundation for deinstitutionalization and the legal rulings that solidified the movement’s objectives. I then will discuss deinstitutionalization’s goals as they align with social work’s goals and rising neoliberal trends. Drawing on both modern and historical literature, I will analyze neoliberal trends that shaped social work during the deinstitutionalization movement, which will provide the necessary scaffolding upon which to build an analysis of tension within social work between micro-level practice and macro-level advocacy. This paper concludes with a reminder of deinstitutionalization’s contemporary implications for policy models of both community and institutionalized care.
Policy and Legal Rulings of Deinstitutionalization
Policy initiatives addressing deinstitutionalization were born at the federal level in the 1960s, however, public attention to mental health issues surfaced in postwar America (Snow & Newton, 1976; Rochefort, 1984; Curran, 2002). In 1946, President Truman signed into law the National Mental Health Act, which gave rise to the National Institute of Mental Health (NIMH) (Freedman, 1967). Policy formation came addressing inadequate mental health care within institutions on the heels of the civil rights movement, and the Mental Retardation Facilities and Community Mental Health Act of 1963 (CMHA) was born within a burst of new social programs and reforms (Patti & Dear, 1975; Rochefort, 1984; Fisher & Karger, 1997). The liberal grassroots period of the 1960s emphasized social justice, and social work’s relationship with community organizing paralleled this emphasis (Fisher & Karger, 1997). The CMHA utilized claims made in the 1961 report of the Joint Commission on Mental Illness and Health (JCMIC) as a guide for deinstitutionalization (Friedman, 2002). This “bold new approach” legislation was the linchpin that initiated the national process of deinstitutionalization (Kennedy, 1963, as cited in Smith & Hobbes, 1966; Snow & Newton, 1976), however claims within the JCMIH report were not supported by the report’s data (Buxbaum, 1966).
In addition to serving as a guide, the CMHA authorized allocation of federal funds to states willing to create CMHCs (Winslow, 1979). Federal funds were only distributed if the CMHC met five specific criteria: inpatient care, outpatient care, partial hospitalization, emergency care, and consultation and education (Smith & Hobbs, 1966; Snow & Newton, 1976; Westerman, Spano & Keyes, 1976). Insufficient knowledge about and prevalence of mental illness meant that policy makers could not accurately predict the scope of services needed by patients (Buxbaum, 1973; Patti & Dear, 1975). Consequently, CMHCs were not created according to need, preventative services within CMHCs failed to be fully-developed, and the needs of the population being deinstitutionalized were not met in full (Smith & Hobbs, 1966; Snow & Newton, 1976).
While policy formation initiated the deinstitutionalization process, three legal rulings focused on patient (and inmate) rights cemented deinstitutionalization’s objectives. In 1966 Baxstrom v. Herod ended extended institutionalization. In 1971 Dixon v. Attorney General of the Commonwealth of Pennsylvania, created sentence-expiration requirements for mentally ill, mandating inmates then be released to civil facilities or mainstreamed into the community (French, 1987). Also in 1971, Wyatt v. Stickney operationalized quality of care. The definition became the “legal criterion for community placement,” (French, 1987, p. 503), including specific terms like “humane” and “least restrictive environment” (French, 1987, p. 503). Though seemingly innocuous, these legal decisions represented a shift in the way America and the government thought of the mentally ill, and as least restrictive environment became the foundation upon which subsequent decisions were made, “client’s rights became the rallying cry for deinstitutionalization advocates” (French, 1987, p. 504[U1] ).
Ratified at the federal level and built upon the Civil Rights movement of the 1960s, deinstitutionalization created a space where social workers found themselves in the dual role of securing a professional status in working with patients while simultaneously advocating for them. Essential to these seemingly conflicting dual-roles are the goals of the deinstitutionalization process and social work, and the neoliberal trends that shaped them.
Goals of Deinstitutionalization, Social Work, and Neoliberalism
An editorial page in Social Work circa 1974 addressed a fundamental and age-old question: What do social workers do? The editorial’s reference to the government’s call for and recognition of clearly defined professional identities denotes the relative ambiguity of and need for definitive answers within the social work profession (S.B., 1974). Kelly’s (1966) placed psychiatric social workers outside the realm of necessary organizing agents within the deinstitutionalization movement. Jertson (1975) questioned the role of a social worker within the context of increasingly populous self-help group therapies. Nearly twenty years after President Kennedy signed the CMHA, DeWeaver (1983) scrutinized social work’s involvement in the mental health field and, specifically, deinstitutionalization of developmentally disabled. Even without clearly defined professional parameters, social work continued to facilitate change at the micro-level, proliferating within the CMHCs as clinicians, administrators and occasionally, as organizers (Winslow, 1979).
Two specific goals of deinstitutionalization ran parallel to the field’s fundamental mission (National Association of Social Workers, 2004). The first major goal of the deinstitutionalization movement centered on creating more “humane and effective treatment for the mentally ill (Dumont & Dumont, 2009). Founded on the principle of “normalization”, which suggested that isolation prohibits highest potential and function, and promoted within a community normal participation and opportunities for mentally ill or developmentally disabled (DeWeaver, 1983; Barbero, 1989; Parish, 2005). Fundamentally, normalization sought to make living conditions for mentally ill as close to living conditions experienced by non-mentally ill and non-developmentally disabled. Another major goal of deinstitutionalization was to make “community mental health services available in appropriate ways to the poor and to agencies serving the poor” (Splaver & Tewart, 1975, p. 54). Both of these goals explicitly aligned with goals of social work, which centered on “self-determination rights and optimization of full potential” (Barbero, 1989, p. 548), and empowering the underserved.
Still other goals of deinstitutionalization aligned explicitly with rising neoliberal trends. The goal to shift power from state to community and public to private (Sigelman, Roeder & Sigelman, 1981), a significant feature of neoliberal philosophy, was based on literature expounding the productive benefits of working in small groups (Harvey, 2005; Kelly, 1996). Another goal of deinstitutionalization was respect for the right to exist in the least restrictive environment, a goal solidified by Halderman v. Pennhurst State School and Hospital (French, 1987). Policy ensuring the least restrictive environment is a similar to policy created to ensure negative liberty, a fundamental neoliberal principle (Harvey, 2005). Neither benevolent nor malevolent (Rochefort, 1989), deinstitutionalization’s focus on shifting power from public to private and the right to live in the least restrictive environment agreed with the rising neoliberal framework regarding social justice. As such, the social work community in whole bifurcated when committing to professional obligations, and like Alinsky’s hyperbolic cries suggest, social work retreated into the comfort of professionalization.
Deinstitutionalization within a Rising Neoliberal State
“When civil liberties (and social activists) were threatened in the McCarthy era of the 1950s, many social workers found protection in casework. When federal funds for progressive social programs became available in the middle of the 1960s, social workers rediscovered the virtues of social justice-oriented community organization. When those same funds evaporated in the late 1960s, the social work professions interest in community organizing followed suit.”
-Fisher & Karger, 1999
During the deinstitutionalization movement, increasing need for professional services such as those of provided by social workers, intersected the drive within social work to professionalize (Fisher & Karger, 1999). Professionalization of social work looked like a burst of new clinicians (Winslow, 1979), research and scholarly publications, and defining new professional parameters post Lyndon Johnson’s War on Poverty. Pursuing professionalization was enhanced by a neoliberal fondness for individualism and “… privatization …” (Spade, 2011, p. 33-34). As such, social workers began to cater to a new client, the middle class. Serving the middle-class on a micro-level helped to professionalize and legitimize the field by linking social work therapy to luxury (Smith & Hobbs, 1966), substantiating the need for private practice.
As deinstitutionalization continued, neoliberal values continued to shape social work. The rhetoric within social work changed as the client became a consumer, a shift reflected in deinstitutionalization-era literature that mirrors a rising neoliberal and capitalist consumer society (Harvey, 2005). Yet another principle of neoliberalism, decentralization of power at the federal level established by the CMHA created variation among state participation at the local level (Sigelman et. a., 1981). Neoliberal policy changes such as privatization, decentralization and deregulation intensified the increasing need for services as the economy shifted from stable to unstable. Eventually, a correlation was drawn between consumers facing both economic and psychological need (Curran, 2002).
Exemplifying social work’s pursuit of professionalization within a neoliberal framework during the deinstitutionalization movement was the Department of Poverty and Welfare in Columbus Ohio (DPW). DPW attempted to meet the increased needs by developing staff units within welfare departments specifically dedicated to mental status evaluation (Splaver & Tewart, 1975). This development boosted self-reliant efficiency and drove down both cost and application waiting period (Splaver & Tewart, 1975), inherently neoliberal goals (Harvey, 2005; Dominelli, 2010). Soon, though needs were being met by trained staff, bureaucratic quarrels over terms like “mental health practitioner” created a basis upon which many trained and previously qualified service providers were no longer qualified (Splaver & Tewart, 1975, p.56). By narrowing the definition of those whom could provide services, DPW effectively embraced the neoliberal trend of creating bureaucratic social policy intended to perpetuate professionalization and privatization (Harvey, 2005). However, this bureaucracy ultimately reduced much needed services, rendering deinstitutionalization practico-inert (Spade, 2011; Young, 2003), as the movement ceased serving the needs of all deinstitutionalized individuals.
As this case was not unique, American states saw tremendous diversity in the success rates of individual CMHCs (Parish, 2005). It is upon this scaffolding of neoliberal principles that I now will investigate enduring tension within the field of social work between micro-level practice and macro-level advocacy.
Tension: Can Micro and Macro Approaches to Social Work Coexist?
Historically, social work’s focus swings through tension between micro-level practice and macro-level advocacy. From professionalization of the 1920s to advocacy associated with the New Deal, the history of social work practice and advocacy seem delicate to balance (Westerman et. al., 1976). Along the same lines, the 1960s saw civil rights advocacy and a boom of social programs, and the 1970s saw a decline in those same social programs, a rise in social work’s service to the middle class and the pursuit of professionalization (Westerman, et. al., 1976; Fisher & Karger, 1999). The historical ebb and flow of micro-level practice and macro-level advocacy has created an enduring tension within the field of social work that is evidenced by the abundance or scarcity of literature from that decade.
As discussed with regard to rising neoliberal trends, micro-level practice that catered to the middle-class remained the predominant focus of social work during deinstitutionalization and the literature detailing service to social work’s new client is plentiful (Smith & Hobbs, 1966; Westerman et. al., 1976; Morrel, 1979). A Smith & Hobbs (1966) survey revealed that the psychotherapy was the primary preferred treatment of the era, acknowledging that the majority of facilities were structured to serve the middle-class. Social worker participation as clinicians within the CMHCs saw a rise of 150% between 1970-1975 (Winslow, 1979). The rise in social work as clinicians serving the middle class was part of the pursuit of professionalization and occurred on a micro-level within practice.
Professionalization within social work had a myriad of multi-faceted manifestations during the deinstitutionalization movement. Ross (1973) highlighted casework and the individual as the agent of change. Smith and Hobbs (1966) performed research linking class and type of treatment received, with findings that reinforced psychotherapy as a middle class service. Smith and Hobbs (1966) made suggestions for social workers to take administrative positions in community centers and Westerman and colleagues (1976) addressed independent practitioners, a direct reference to licensure. Social workers were supposed to be liaisons and experts (Austin, 1970), therapists (Westerman, et. al, 1976), and the keeper of patient/consumer complaints (Ross, 1973). They were not expected to be macro-level social leaders, organizers, or activists (Kelly, 1966). These expectations contributed to social work deinstitutionalization participation.
Locatable literature on social work’s macro-level advocacy during the deinstitutionalization movement is scarce. Long after the McCarthy Administration, social work seemed to have no politically powerful allies upon which to lean, and no voice with which to advocate (Keith-Lucas, 1975). Though social work sought an ally to empower the profession, Community organizing and social activism was the work of the community in which those deinstitutionalized populations would be placed (Kelly, 1966; Smith & Hobbs, 1966). The most effective leaders were often parents or activists from single-purpose coalitions (Parish, 2005). “In actual fact, only a small percentage of mental health professionals ever left their offices and wards or became involved in any service activity that was genuinely extraclinical [sic]” (Snow & Newton, 1976, p. 589). Macro-level advocacy is nearly-invisible in deinstitutionalization-era literature.
Furthering the concept of scarce macro-literature is the focus within the scarce literature, which often calls for more macro-level advocacy. Two years after the CMHA was signed, Buxbaum (1966) predicted setbacks due to insufficient treatment facilities in communities, the organization of which had been left to members of the community (Kelly, 1966). Morell (1979) criticized the lack of policy implementation that ensured needs of deinstitutionalized patients were met and French (1985) attributed the failure of policy implementation to the absence of structural accountability in the CMHA. Patti and Dear (1975) had called social workers to Community organization and action early in the movement, yet it’s arguable whether social work answered the call.
Was Alinsky appropriate in his statement about social workers retreating into professionalism whenever times get tough? Or was Bertha Reynolds right when she said, “Professionalism can coexist comfortably alongside partisan political activity” (Bertha Reynolds cited by Fisher & Karger, 1997, p. 125). While history may be cyclical, the future may be open to change.
Conclusion: Implications for the Profession and Person
This paper has reviewed the history of deinstitutionalization in terms of policy formation and legal rulings. This paper has also examined neoliberal trends that shaped social work practice during deinstitutionalization and the tension between micro-level practice and macro-level advocacy that shaped social work’s participation. In sum, tension within the field of social work between micro- and macro-level participation was reified by the rising neoliberal trends surrounding deinstitutionalization and the pitfalls that riddled the CMHA. This created a platform upon which the deinstitutionalization movement failed to achieve its broader intendments. Similarly, the field of social work failed to adequately participate in a movement that should have been characterized by the profession’s engagement in social activism and community organizing. While some innovative treatments like milieu and small-group therapy did arise within the deinstitutionalization movement (Boettcher & Schie, 1975), far too many mentally ill individuals were excluded for deinstitutionalization to be considered a success (Smith & Hobbs, 1966).
Deinstitutionalization and social work’s involvement within the movement has far reaching implications. While it’s important to acknowledge the benefits of CMHCs such as improved mental health access for the poor, it is essential to address deinstitutionalization’s shortcomings as we look to the future of healthcare. As counter-finality to minimal supervision in the to CMHCs, many mentally ill individuals never arrived (Austin, 1970; Steadman et. al., 1998). A boom in the homeless population, a direct correlate of deinstitutionalization, is a poignant example of a totally unrestricted environment. A boom in the jail population is also a direct correlate of deinstitutionalization, and both of these act as a reminder of our inability to provide adequate and accessible mental health care for all Americans (Joe, 1995; Brownell & Roberts, 2002).
Looking to the future using Young’s (2003) concept of political responsibly, it’s critical that social work simultaneously be involved in micro-, mezzo- and macro-levels of mental health care, and responsible for creating inclusive programs that plan for the long-term while keeping watch on influential trends that focus on the bottom line, like neoliberalism. Instead of writing policy that centers on the least restrictive environment, we can focus instead on the most therapeutic environment (French, 1987). We can structure accountability into our mental health policies, ensuring systems of responsibility post-implementation. If we do not, and continue to disappear into professionalization when also we should be social activists, social work will be no more than a handmaiden to the status quo (Crethar, Rivera & Nash, 2008).
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Class: 500 – Intellectual and Historical Foundations of Social Work