The History of The History of Mental Health Mental Health

TreatmentTreatment

Jess P. Shatkin, MD, MPHJess P. Shatkin, MD, MPH

Vice Chair for EducationVice Chair for Education

NYU Child Study CenterNYU Child Study Center

New York University School of New York University School of MedicineMedicine

Learning ObjectivesLearning Objectives

Residents will be able to:Residents will be able to:

1)1) Identify the key historical events Identify the key historical events which led which led to the growth of asylumsto the growth of asylums

2)2) Describe how the fields of psychiatry Describe how the fields of psychiatry and and clinical psychology grew and changed clinical psychology grew and changed over over the past 300 yearsthe past 300 years

3)3) Select four factors which led to the Select four factors which led to the eventual eventual closure of asylums and the closure of asylums and the present day focus present day focus on community careon community care

Two ExtremesTwo Extremes

The history of the care and The history of the care and treatment of the mentally ill treatment of the mentally ill represents an endless journey represents an endless journey between two extremes:between two extremes:

1)1) Confinement in a mental hospitalConfinement in a mental hospital

2)2) Living in the communityLiving in the community

Humoral TheoryHumoral Theory Following upon humoral theories of Following upon humoral theories of

illness (both mental and physical), illness (both mental and physical), disease was caused by an imbalance disease was caused by an imbalance of the humorsof the humors

The role of the physician was to The role of the physician was to assist in restoring equilibriumassist in restoring equilibriumHotHot ColdCold DryDry WetWet

EarthEarth AirAir FireFire WaterWater

Black BileBlack Bile Yellow B.Yellow B. PhlegmPhlegm BloodBlood

Three Primary Three Primary ProceduresProcedures

Bleeding (cut)Bleeding (cut) Vomiting (emetic)Vomiting (emetic) Purging (laxative)Purging (laxative)

These treatments were nonspecific and These treatments were nonspecific and applied to applied to ““all that ails youall that ails you””

They long outlived the theories that They long outlived the theories that justified them (even into the 19justified them (even into the 19thth century) century)

Even once realized to be invalid Even once realized to be invalid scientifically, doctors would sometimes scientifically, doctors would sometimes use an eclectic approach use an eclectic approach

1717thth Century Century Society is rural and agriculturalSociety is rural and agricultural Communities are small and scatteredCommunities are small and scattered Mental illness is an individual not Mental illness is an individual not

societal problem to be handled by the societal problem to be handled by the family and not the Statefamily and not the State

Concepts of insanity are fluid and not Concepts of insanity are fluid and not medical, arising more from cultural, medical, arising more from cultural, popular, and intellectual theoriespopular, and intellectual theories

Monty PythonMonty Python’’s Village Idiots Village Idiot

1818thth Century American Century American ColonialismColonialism

Institutionalization first appears by the early Institutionalization first appears by the early 1700s 1700s

Based upon the English principle that society had Based upon the English principle that society had a corporate responsibility to the poor and a corporate responsibility to the poor and dependentdependent

Largely precipitated by demographic shifts and Largely precipitated by demographic shifts and industrialization leading to population increases industrialization leading to population increases in cities and a relative increase in the proportion in cities and a relative increase in the proportion of sick and dependent personsof sick and dependent persons

Geographic mobility leads to less neighborhood Geographic mobility leads to less neighborhood cohesioncohesion

Medical considerations were minimal; the real Medical considerations were minimal; the real issues were economic and public safetyissues were economic and public safety

Undifferentiated welfare institutions and Undifferentiated welfare institutions and almshouses treated the aged, infirm, very young, almshouses treated the aged, infirm, very young, and mentally illand mentally ill

HospitalsHospitals

A recent invention created by affluent A recent invention created by affluent trustees for the less fortunate, not for trustees for the less fortunate, not for themselvesthemselves

As late as 1873 there were only 178 As late as 1873 there were only 178 hospitals in the US (1/3 of which were for hospitals in the US (1/3 of which were for the mentally ill) with a total of fewer than the mentally ill) with a total of fewer than 50,000 beds50,000 beds

Currently on the order of 15K hospitals in Currently on the order of 15K hospitals in the U.S. and approximately 1.8 million the U.S. and approximately 1.8 million bedsbeds

Moral TreatmentMoral Treatment

Preindustrial people tended to accept Preindustrial people tended to accept their fate (omnipotent God)their fate (omnipotent God)

The 18The 18thth Century Enlightenment Century Enlightenment stressed innovation and problem-solving stressed innovation and problem-solving by conscious and purposeful human by conscious and purposeful human interventionintervention

Pinel created Pinel created ““moral treatmentmoral treatment”” which which suggested that environmental changes suggested that environmental changes could affect an individualcould affect an individual’’s psychology s psychology and thereby change his behaviorand thereby change his behavior

The Birth of the AsylumThe Birth of the Asylum

Pinel rejected the prevailing belief Pinel rejected the prevailing belief that madness was incurable, and he that madness was incurable, and he suggested that confinement in a well suggested that confinement in a well ordered asylum was indispensableordered asylum was indispensable

Benjamin RushBenjamin Rush William Tuke (created the York William Tuke (created the York

Retreat, 1792)Retreat, 1792)

Asylums (late 1700s & early Asylums (late 1700s & early 1800s)1800s)

Bedlam (Bethlehem Hospital) was Bedlam (Bethlehem Hospital) was established in the 13established in the 13thth Century but was a Century but was a storage facilitystorage facility

Well established American asylums Well established American asylums included McLean (Boston), included McLean (Boston), Bloomingdale (NYC), Butler Bloomingdale (NYC), Butler (Providence), Pennsylvania Hospital (Providence), Pennsylvania Hospital (Philadelphia), and the Hartford Retreat (Philadelphia), and the Hartford Retreat (Connecticut)(Connecticut)

These were set up for wealthy families These were set up for wealthy families who would not mix with racial and who would not mix with racial and ethnic minorities, for whom almshouses ethnic minorities, for whom almshouses remained the only placeremained the only place

AMSAIIAMSAII In 1844 the Association of Medical In 1844 the Association of Medical

Superintendents of American Institutions Superintendents of American Institutions for the Insane (AMSAII) was foundedfor the Insane (AMSAII) was founded

Coincident with the emergence of Coincident with the emergence of Psychiatry, the 2Psychiatry, the 2ndnd subspecialty after subspecialty after surgerysurgery

Later to become the American Later to become the American Psychiatric AssociationPsychiatric Association

The first medical specialty organization The first medical specialty organization in the nationin the nation

Founded the American Journal of InsanityFounded the American Journal of Insanity

Public AsylumsPublic Asylums By the 1820s it became clear that the wealthy By the 1820s it became clear that the wealthy

asylums could not care for the poor who were asylums could not care for the poor who were overwhelming the almshouses and urban overwhelming the almshouses and urban streetsstreets

During the second half of the 19During the second half of the 19thth Century, Century, the responsibility for the insane slowly fell the responsibility for the insane slowly fell under the jurisdiction of state asylumsunder the jurisdiction of state asylums

This movement went on for about 100 years, This movement went on for about 100 years, when asylum populations hit their peak in when asylum populations hit their peak in 1955 (roughly 600K patients at that time)1955 (roughly 600K patients at that time)

The massive growth of asylums was more of The massive growth of asylums was more of an accident than a proper plan (custodial)an accident than a proper plan (custodial)

Psychiatry and AsylumsPsychiatry and Asylums Asylums predated psychiatry, not vice Asylums predated psychiatry, not vice

versaversa A symbiotic relationship between asylums A symbiotic relationship between asylums

and psychiatrists developed, each and psychiatrists developed, each conferring legitimacy upon the otherconferring legitimacy upon the other

Psychiatry worked hard to establish itself Psychiatry worked hard to establish itself as the proper leader of asylumsas the proper leader of asylums Medicine was an unstable careerMedicine was an unstable career There were lots of non-allopathic healers who There were lots of non-allopathic healers who

challenged the primacy of MDschallenged the primacy of MDs

Moral Treatment in Moral Treatment in AsylumsAsylums Insanity was due to two causes: (1) Lesions in Insanity was due to two causes: (1) Lesions in

the brain; and (2) moral causesthe brain; and (2) moral causes Moral insanity was due to willful violation of Moral insanity was due to willful violation of

natural laws that governed human behavior natural laws that governed human behavior (such that immorality, improper living (such that immorality, improper living conditions, and stresses could precipitate conditions, and stresses could precipitate illness)illness)

Because physical causes could not be Because physical causes could not be addressed, treatment focused on the moral addressed, treatment focused on the moral causes (masturbation, alcohol abuse, excessive causes (masturbation, alcohol abuse, excessive ambition, jealousy, pride, etc.)ambition, jealousy, pride, etc.)

Treatment was a synthesis of medicines, religion Treatment was a synthesis of medicines, religion and morality (OT, religious exercises, and morality (OT, religious exercises, recreation, etc)recreation, etc)

Heroic treatments were still used but unjustifiedHeroic treatments were still used but unjustified

Psychiatric Job Security Psychiatric Job Security (1830-1900)(1830-1900)

Asylum physicians had a good gig Asylum physicians had a good gig goinggoing

They were influential, enjoyed a well They were influential, enjoyed a well paid job, and had high status in paid job, and had high status in medicinemedicine

Little interest in joining the AMA upon Little interest in joining the AMA upon its founding in 1847its founding in 1847

The Reality of Asylum Life The Reality of Asylum Life (late 1800s)(late 1800s)

But asylum life was rapidly becoming a real But asylum life was rapidly becoming a real mess, & by the close of the century asylum mess, & by the close of the century asylum legitimacy was being questioned:legitimacy was being questioned: Moral treatment demanded small settings, but Moral treatment demanded small settings, but

patient numbers kept increasingpatient numbers kept increasing Psychiatry became largely managerial and Psychiatry became largely managerial and

administrativeadministrative Decreases in infant mortality meant more Decreases in infant mortality meant more

dependent elderly, only some of whom were dependent elderly, only some of whom were senilesenile

Mental hospitals became surrogate old age Mental hospitals became surrogate old age homeshomes

Repositories for those with tertiary syphilisRepositories for those with tertiary syphilis Mortality rates in asylums were 5x the general Mortality rates in asylums were 5x the general

population due to over-crowdingpopulation due to over-crowding

Germ TheoryGerm Theory General medicine now becomes legitimate General medicine now becomes legitimate

and powerfuland powerful Psychiatrists scrambled to identify new Psychiatrists scrambled to identify new

careers outside of institutions, articulating careers outside of institutions, articulating novel treatments and theoriesnovel treatments and theories

A preventative role is seen and following upon A preventative role is seen and following upon Freudian theory neurosis and stress become Freudian theory neurosis and stress become legitimate illnesses worth treatinglegitimate illnesses worth treating

Neurology tries to discredit psychiatryNeurology tries to discredit psychiatry AMSAII changes its name to the American AMSAII changes its name to the American

Medico-Psychological Association (AMPA) to Medico-Psychological Association (AMPA) to reflect its desired focus as a more reflect its desired focus as a more ““medicalmedical”” specialty and to dissociate itself from specialty and to dissociate itself from institutionsinstitutions

Dynamic PsychiatryDynamic Psychiatry Viewed psychic distress along a continuum Viewed psychic distress along a continuum

from normal to abnormalfrom normal to abnormal Treatment focus shifted away from asylums Treatment focus shifted away from asylums

and toward psychiatric institutes and and toward psychiatric institutes and hospitalshospitals

Pathological (Psychiatric) Institute Pathological (Psychiatric) Institute established in NYC in 1895established in NYC in 1895

The appearance of the psychiatric hospital The appearance of the psychiatric hospital (mission: evaluation, treatment, and (mission: evaluation, treatment, and referral)referral) Bellevue Adult Psych Unit 1879Bellevue Adult Psych Unit 1879 Child Unit 1924Child Unit 1924 Adolescent Unit 1927Adolescent Unit 1927

PsychopathyPsychopathy

Psychiatry stretched beyond Psychiatry stretched beyond psychopathology to include conduct and psychopathology to include conduct and other behavioral disorders within its other behavioral disorders within its domain (sexual behavior, criminality, etc.)domain (sexual behavior, criminality, etc.)

This occurs partially because of genuine This occurs partially because of genuine concern and interest and partly because concern and interest and partly because of the desire to move somewhat away of the desire to move somewhat away from the chronic and persistently from the chronic and persistently mentally ill who are housed in asylumsmentally ill who are housed in asylums

Striving for LegitimacyStriving for Legitimacy

The AMPA becomes the APA in 1921The AMPA becomes the APA in 1921 The Journal of Insanity becomes the The Journal of Insanity becomes the

American Journal of PsychiatryAmerican Journal of Psychiatry Psychiatry is unable to gain a Psychiatry is unable to gain a

foothold in universities before WWIIfoothold in universities before WWII The first professional board, the The first professional board, the

American Board of Psychiatry and American Board of Psychiatry and Neurology, is founded in 1934 and Neurology, is founded in 1934 and provides for board certificationprovides for board certification

Home CareHome Care

In an effort to decrease costs to the In an effort to decrease costs to the states, home care becomes an option states, home care becomes an option in the 1920s and 30s (Depression era)in the 1920s and 30s (Depression era)

Families either couldnFamilies either couldn’’t or wouldnt or wouldn’’t t manage their sick relatives at homemanage their sick relatives at home

Meanwhile, overcrowding continues Meanwhile, overcrowding continues at asylums, and there is less and less at asylums, and there is less and less money available to take care of the money available to take care of the infrastructureinfrastructure

New Somatic TreatmentsNew Somatic Treatments All from Europe in the 1920s – 30sAll from Europe in the 1920s – 30s Quickly adopted in the US because of the Quickly adopted in the US because of the

great desire to treat the illgreat desire to treat the ill Received with great optimismReceived with great optimism The states were spending lots of money on The states were spending lots of money on

custodial carecustodial care Psychiatry was anxious to legitimize itself as Psychiatry was anxious to legitimize itself as

a true medical specialtya true medical specialty Regardless of their true utility, these Regardless of their true utility, these

somatic therapies breathed great hope into somatic therapies breathed great hope into American psychiatry on the eve of WWIIAmerican psychiatry on the eve of WWII

Fever TherapyFever Therapy Jules Wagner-Jauregg (University of Jules Wagner-Jauregg (University of

Vienna)Vienna) Based upon the observation that mental Based upon the observation that mental

symptoms occasionally disappeared in symptoms occasionally disappeared in mental patients ill with typhoid fevermental patients ill with typhoid fever

He injected malarial blood into mentally He injected malarial blood into mentally ill patients (aka malarial therapy)ill patients (aka malarial therapy)

Received the Nobel Prize in 1927Received the Nobel Prize in 1927 Used commonly with syphilitics in the USUsed commonly with syphilitics in the US No evidence of its utilityNo evidence of its utility

Diabetic ComaDiabetic Coma

Manfred Sakel, Viennese physicianManfred Sakel, Viennese physician Based upon his observation that diabetic Based upon his observation that diabetic

drug addicts treated with insulin in 1928 drug addicts treated with insulin in 1928 had a decrease in psychotic symptomshad a decrease in psychotic symptoms

By the mid-1930s he was routinely using By the mid-1930s he was routinely using this treatment in psychotic illnesssthis treatment in psychotic illnesss

The hypoglycemic state resulted in a coma The hypoglycemic state resulted in a coma relieved by administration of sugarrelieved by administration of sugar

Lacked a rationale theory and didnLacked a rationale theory and didn’’t workt work

Metrazol TreatmentMetrazol Treatment

Ladislas von Meduna, Hungarian Ladislas von Meduna, Hungarian physicianphysician

Based upon the observation that Based upon the observation that epileptics are rarely schizophrenic, he epileptics are rarely schizophrenic, he employed metrazol to induce employed metrazol to induce convulsionsconvulsions

He postulated a He postulated a ““biological antagonismbiological antagonism”” between the two illnessesbetween the two illnesses

Little data was collectedLittle data was collected

The Problems with ShockThe Problems with Shock

Many potential side effects to insulin and Many potential side effects to insulin and metrazolmetrazol

Insulin comas were sometimes fatal and Insulin comas were sometimes fatal and could induce seizures, pulmonary edema, could induce seizures, pulmonary edema, and respiratory distress (mortality rate of 1 – and respiratory distress (mortality rate of 1 – 5%)5%)

Metrazol was safer but could lead to Metrazol was safer but could lead to fractures and respiratory distressfractures and respiratory distress

Still, these treatments became quickly in Still, these treatments became quickly in vogue and were to be found in every asylum vogue and were to be found in every asylum and psychiatric hospital by 1940and psychiatric hospital by 1940

Introducing ElectroshockIntroducing Electroshock A safer alternative to metrazolA safer alternative to metrazol Developed by Ugo Cerletti (Italian physician Developed by Ugo Cerletti (Italian physician

who believed in shock treatment but found who believed in shock treatment but found insulin and metrozol too dangerous)insulin and metrozol too dangerous)

Was shown to work effectively, particularly Was shown to work effectively, particularly with affective disorders and psychotic mood with affective disorders and psychotic mood statesstates

The problem was that psychiatric nosology The problem was that psychiatric nosology was so shotty as were diagnoses themselves was so shotty as were diagnoses themselves that it was hard to apply this treatment to that it was hard to apply this treatment to the the ““rightright”” patient patient

LobotomyLobotomy

Egas Moniz, PortugalEgas Moniz, Portugal Developed by Moniz in 1935, it was a Developed by Moniz in 1935, it was a

runaway hit with US physiciansrunaway hit with US physicians This treatment had a firmer theoretical This treatment had a firmer theoretical

justification than the shock therapiesjustification than the shock therapies A simple surgical procedure that A simple surgical procedure that

involved severing the nerve fibers of the involved severing the nerve fibers of the frontal lobefrontal lobe

Between 1936 and 1951, at least 19,000 Between 1936 and 1951, at least 19,000 lobotomies were performed in the USlobotomies were performed in the US

World War IIWorld War II After 1945 there became a great After 1945 there became a great

emphasis upon shifting care away from emphasis upon shifting care away from hospitals and into the communityhospitals and into the community

The war had influenced psychiatrists:The war had influenced psychiatrists: They saw the impact of environmental They saw the impact of environmental

stressstress They saw that non-institutional treatment They saw that non-institutional treatment

could be beneficialcould be beneficial They saw how pervasive these illnesses They saw how pervasive these illnesses

were; that is, the breadth of psychiatric were; that is, the breadth of psychiatric illness became more evident (not just the illness became more evident (not just the severe and persistent illnesses)severe and persistent illnesses)

Psychoanalytic TheoryPsychoanalytic Theory By the end of WWII, the APA became By the end of WWII, the APA became

more psychodynamic and analyticalmore psychodynamic and analytical These same leaders took control of These same leaders took control of

university departments of psychiatryuniversity departments of psychiatry There became a contrast between There became a contrast between

psychiatrists focused on institutional psychiatrists focused on institutional patients (with severe illness of patients (with severe illness of presumed biological etiology) and presumed biological etiology) and those focused on psychodynamic and those focused on psychodynamic and community focused treatmentcommunity focused treatment

Post-War Changes in Post-War Changes in HealthcareHealthcare

After 1945, the nationAfter 1945, the nation’’s healthcare s healthcare system underwent major changes as system underwent major changes as a result of:a result of:

1)1) Federal initiativesFederal initiatives

2)2) The development of 3The development of 3rdrd party insurance party insurance

3)3) A commitment to medical technology and A commitment to medical technology and specializationspecialization

The NIMH was established and so The NIMH was established and so ended a long period of federal ended a long period of federal passivity in mental health policypassivity in mental health policy

CMHCsCMHCs Community Mental Health Centers Community Mental Health Centers

were established in every state were established in every state during the 1950s on the theories of:during the 1950s on the theories of:

1)1) PreventionPrevention2)2) Early identification and treatment Early identification and treatment

(following a psychodynamic model)(following a psychodynamic model)3)3) Follow-up care for institutionalized and Follow-up care for institutionalized and

hospitalized patientshospitalized patients State contributions outpaced federal State contributions outpaced federal

allocations because of their optimism allocations because of their optimism and potential financial savingsand potential financial savings

PsychologyPsychology An historically philosophical field that became An historically philosophical field that became

experimental in the late 1800s in Germanyexperimental in the late 1800s in Germany Following upon the work of Watson and Skinner, Following upon the work of Watson and Skinner,

claimed to have amassed much data by the claimed to have amassed much data by the 1940s, having derived explanatory theories 1940s, having derived explanatory theories relevant to normal and abnormal behaviorrelevant to normal and abnormal behavior

Psychiatrists had little evidence to support their Psychiatrists had little evidence to support their treatments and were generally not well trained treatments and were generally not well trained in research methodsin research methods

All parties concluded research must be All parties concluded research must be multidisciplinary, and the NIMH began to multidisciplinary, and the NIMH began to support both fields in research and clinical support both fields in research and clinical trainingtraining

Milieu Therapy (1950s)Milieu Therapy (1950s) Aka Aka ““therapeutic communitytherapeutic community”” Proposed that the environment of an asylum Proposed that the environment of an asylum

or hospital could assist in the treatment of or hospital could assist in the treatment of the mentally ill by organizing a community the mentally ill by organizing a community or social organization which itself would be or social organization which itself would be healing and toward which everyone is healing and toward which everyone is expected to make a contribution expected to make a contribution

This contrasted with authoritarian mental This contrasted with authoritarian mental hospitals in the same way that US hospitals in the same way that US democracy contrasted with Soviet democracy contrasted with Soviet dictatorship (Cold War)dictatorship (Cold War)

Optimism Reigns Optimism Reigns SupremeSupreme

During the 1950s, psychiatry was once During the 1950s, psychiatry was once again optimistic:again optimistic:

1)1) At least one somatic treatment worked really At least one somatic treatment worked really well (e.g., ECT)well (e.g., ECT)

2)2) A well thought out theoretical psychodynamic A well thought out theoretical psychodynamic foundation had been effectively establishedfoundation had been effectively established

3)3) Milieu Therapy had emergedMilieu Therapy had emerged However, it was realized that However, it was realized that

psychotherapeutic treatment varied psychotherapeutic treatment varied greatly by practitioner and was not greatly by practitioner and was not standardizedstandardized

Psychotropic Psychotropic MedicationsMedications

Chlorpromazine (Thorazine) was synthesized Chlorpromazine (Thorazine) was synthesized in the late 1950s and was the first in the late 1950s and was the first psychoactive drugpsychoactive drug Initially developed as an antihistamineInitially developed as an antihistamine

It helped to bring together biological and It helped to bring together biological and psychodynamic psychiatrists (who also found psychodynamic psychiatrists (who also found this and other medications useful)this and other medications useful)

Many effective drugs followed and helped Many effective drugs followed and helped move patients into the communitymove patients into the community Necessitated all sorts of new practitioners (psych Necessitated all sorts of new practitioners (psych

nurses, social workers, clinical psychologists)nurses, social workers, clinical psychologists) Of these only psychologists threatened the Of these only psychologists threatened the

supremacy of psychiatry & psychologistssupremacy of psychiatry & psychologists’’ desire desire to do psychotherapy led to a big fightto do psychotherapy led to a big fight

Medicaid and MedicareMedicaid and Medicare Came on the heals of the Civil Rights Movement Came on the heals of the Civil Rights Movement

The first time that patient rights were really discussed The first time that patient rights were really discussed Medicaid (1965) provided a better reimbursement Medicaid (1965) provided a better reimbursement

for nursing home care than for mental hospitalsfor nursing home care than for mental hospitals In 1972 Social Security Disability Insurance (SSDI) In 1972 Social Security Disability Insurance (SSDI)

was expanded to include the mentally disabled & was expanded to include the mentally disabled & the Social Security Act was amended to provide the Social Security Act was amended to provide coverage for people who didncoverage for people who didn’’t qualify for benefits t qualify for benefits Supplemental Security Income (SSI) was set up to Supplemental Security Income (SSI) was set up to

provide income for those whose disabilities made them provide income for those whose disabilities made them incapable of holding a job (e.g., elderly, mentally or incapable of holding a job (e.g., elderly, mentally or physically disabled, blind, etc.)physically disabled, blind, etc.)

SSDI and SSI made it still easier for the mentally ill SSDI and SSI made it still easier for the mentally ill to leave hospitals since federal payments would to leave hospitals since federal payments would allow them to live in the communityallow them to live in the community

The Reagan EraThe Reagan Era

Reagan reversed 3 decades of federal Reagan reversed 3 decades of federal involvement in the care of the mentally involvement in the care of the mentally ill in 1981 with the Omnibus Budget ill in 1981 with the Omnibus Budget Reconciliation ActReconciliation Act

Funding was shifted away from the Funding was shifted away from the federal government and to states and federal government and to states and communitiescommunities

Billions of dollars were eventually cutBillions of dollars were eventually cut

The Asylum Era at an The Asylum Era at an EndEnd

4 major factors contributed to their 4 major factors contributed to their closure:closure:

1)1) The Civil Rights MovementThe Civil Rights Movement

2)2) The development of pharmacological The development of pharmacological interventionsinterventions

3)3) Legislation demanding patients be Legislation demanding patients be treated in the treated in the ““least restrictive settingleast restrictive setting”” (re: community)(re: community)

4)4) Reagan era decreases in fundingReagan era decreases in funding- Psychosis or major mental illness becomes no - Psychosis or major mental illness becomes no

longer a reason to hospitalize someone longer a reason to hospitalize someone