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November 1st, 2015

The Deinstitutionalization of Mental Illness:


The effect of World War II on mental health awareness and mental health service reform

Throughout the nineteenth century, asylums became the main provider of mental
health care around the world. They were initially created with a therapeutic objective, but by
the end of the century they mainly had a confinement purpose (Shorter, 1997). It was not
until the twentieth century when a series of factors triggered important changes in the field of
psychiatry that shifted the approach to mental health services and policies. World War II
ultimately served as the catalyst that triggered this paradigm shift.
The experiences of World War I started bringing up some issues regarding the state of
mental health care in the United States. Thomas Salmon, the main voice of psychiatry at the
time, started raising his concerns of how psychiatry had been ignored or unnoticed and had
ultimately been isolated from traditional medicine. He saw the experiences of World War I as
having the potential to advance the field of psychiatry both in treatment development and
public awareness (Menninger, 1948). The mental illnesses suffered by soldiers brought some
attention to mental health issues and provided an unprecedented opportunity to gain
knowledge regarding the nature and possible treatment of these problems. However, the
extensive knowledge gained during the war did not have the effect Salomon predicted and
soon were forgotten or neglected, eclipsed by other national crisis that took the spotlight in
the years between the first and second World Wars (Menninger, 1948). World War I did not
have a significant effect in changing the state of mental health services in the United States,
which really came about after World War II, raising the issue of why similar war experiences
regarding mental health had differing impacts.
The approach to mental health issues, including social stigmas and treatments, has
undergone numerous changes throughout history. It is important to understand that even
today, the notions surrounding these issues are constantly being influenced and changed. One
of the most significant shifts in the approach to these issues came with the first-ever
appearance of government policies in the United States for mental health service provision
after World War II. This marked a crucial moment in the development of the field of
psychiatry and, despite the failure of the first policies, set the base for further development
and acceptance of mental illness as a public health concern. The demise of the asylum as the
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symbol of institutionalized care that cast out mentally ill patients, shifted to the communitybased care. This represented a radical shift regarding the approach towards treatment and
social attitudes regarding mental illness, so this paper primarily focuses on the changes in
mental health service policies and awareness that occurred from World War II up until the
1960s.
World War II was the dominant factor that served as a catalyst for the reform of mental
health services in the U.S. from asylums to community-based psychiatric care, a profound
shift in the perception and approach regarding mental illness and its treatment.
The horrible state of asylums was worsened by the shift in priorities during war that
lead to sharp budget cuts and further neglect of public mental health hospitals. This ultimate
blow to the system produced the demise of the asylum as the main provider of mental health
services and the post war public outcry towards these institutions. In addition, the new
situations encountered during the war effort, involving the psychiatric effects of armed
conflict, brought the decades-long stagnation of the field to an end. Psychiatry, which had
been moving away from the public, government and professionals, went back to the center of
attention as a result of World War II. Finally, the war experiences of psychiatrists led to a new
optimism regarding prevention and treatment of mental illness that fueled a reformist
movement. This was the catalyst for a series of changes in policies regarding mental health
and the advancement of the field. It played an important role in significantly destigmatizing
mental illness and normalizing psychiatry to make it relatable to society as a whole.

World War II made the situation of the patients in asylums even worse than it already
was by decreasing funding as a result of changing priorities. At the start of World War II, the
conditions of mental health hospitals that had been implemented the previous century with a
therapeutic philosophy were abominable. The state of these institutions had been getting
worse since the end of the nineteenth century, and by the time World War I started, asylums
could be thought of as massive warehouses for mental illness patients (Shorter, 1997).
Originally, the problem was not the nature of the approach to mental illness of these
institutions, which in fact had reformist qualities, but the evolution of the institutions from a
therapeutic to a custodial role. The system collapsed under the pressure of the overwhelming
increase in number of patients towards the end of the century, which meant they had little time
for treatment and could just house patients (Shorter, 1997). The great depression in the 1930s
forced budget cuts and made the situation of mental hospitals even worse, going into World
War II with already inhumane conditions. When the U.S. entered the conflict, lack of funding
further deteriorated the asylums (Bell, 1989). Despite the fact that psychiatry played a role in
the war effort, it was focused on the troops and not on the mental hospitals that already
existed. As a result, the outburst of the war increased the neglect towards the institutions that
at that point in time only kept the mentally ill as outcasts separated from society. Cuts in
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funding increased the oppressive nature of asylums and this worsening situation was an
important factor in setting the scene for the post-war public outrage regarding public mental
hospitals. In the U.S. the situation did not go as far as it did in Britain, where the mobilization
for war involved the use of mental hospitals as hospitals for war casualties and ordered to
reduce the space reserved for mental patients (Armour, 1981). In spite of this, the war did
worsen the quality of life of the patients in American asylums to a great extent, and it was just
a matter of time that public attention shifted towards them.

The psychiatric issues that came up during World War II regarding combat disorders
and the mental health of the troops brought the field back to the domain of public and
government interest. The status of the field had been consistently deteriorating since the
downfall of the asylum started. Throughout the war there was a very significant shift in media
attention towards the draft rejections as a result of psychiatric screening, as well as the
unexpectedly large number of casualties related to psychiatry (Morrissey, 1989). This
situation made the attention of the public return to an issue that had been increasingly
neglected before the war effort started. The field of psychiatry had been stagnating for
decades since the asylum system started failing in its therapeutic objectives.
World War I had shown some evidence of mental breakdown during battle, so when it
was time to prepare for World War II there was an increased interest towards psychiatry as
some believed that screening would avoid these issues from occurring to the troops drafted for
the conflict (Jones, 2000). The screening efforts brought psychiatry back into the public
interest domain because there was a large percentage of men being rejected. This large
number of rejections as a result of psychiatric screening brought both the public and the
governments attention to the issue of mental health (Armour, 1981). In spite of having some
influence in bringing attention towards psychiatry, screening efforts alone were not a crucial
factor in the increased awareness towards mental illness that was observed during the war. It
was the apparent failure of screening that made public and government start thinking of
mental health as a national health issue. The large number of psychiatric casualties shifted
attention to the prevention of mental health problems in the troops. The rejection rates had
been six times bigger than the ones in World War I and the incidence of mental disorders still
doubled, which proved a dramatic failure of the screening programs and brought criticism to
psychiatry (Pols, Oak, 1995).
The War highlighted the fact that there was a significant shortage of mental health
professionals. In fact, in 1940 only four of the medical officers assigned to psychiatric
practice in the armed forces were qualified professionally (Menninger, 1948). Thus, there was
an increase in the governments interest in training personnel during the war that could serve
as mental health professionals. The conflict attracted new young physicians to the field that
would have probably chosen other medical specialties due to the curtailed status of psychiatry
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(Grob, 1991). Before the war, psychiatry had reached a point where becoming a specialist in
the field would in most cases lead to an outcast life living in an asylum with little hope for
having an actual contribution in the healing of patients. With the apparent necessity of mental
health professionals that became evident during the war, a new window of opportunity was
created for young physicians who entered the field. War offered these new physicians entering
the field the chance for innovation and testing new methods (Cameron, 1989), which made
the field not only more important in the eyes of the public and government, but also more
appealing to potential professionals. There were a large number of veterans returning to
civilian life that had been diagnosed with psychiatric disorders and it made the nation more
conscious about the issues regarding mental health than ever before (Menninger, 1948). World
War II reactivated the evolution of the paradigms regarding psychiatry because it not only
created the opportunity for development and change, but it also dramatized mental
disturbance as a major problem in society (Bell, 1989, p.108)
World War II played a central role in the change in the governments attitude towards
mental health services. Inspections of facilities after the war proved that the situation in
mental hospitals was a disaster and demonstrated the need for reforms (Armour, 1981). As a
result of the war unveiling the deficiencies in the countrys mental health system, there was a
large shift towards federal intervention in mental health services and a strong push for policies
regarding mental health issues. Simultaneous to this increasing notion that the federal
government needed to fix certain problems in the mental health service system, a reformist
movement arose and accelerated the shift in the way government policies addressed mental
health to a community-based system. After the war, which laid the foundations for change,
mental health policy evolved greatly (Grob, 1995).

The psychiatrists that had participated in the war effort, mostly young and innovative,
were very optimistic after the war because of the success of their treatments. The war had
provided them an opportunity to develop and test new techniques and their success showed
great promise for a new approach to psychiatry. Regarding the impact in postwar psychiatry
of these men that experienced the war, Gerald Grob argues that out of their encounter with
war and the lessons they drew came the outlines of a new paradigm that in the postwar era
would prove a potent force for innovation. (Grob, 1991, p. 10). William Menninger, the
director of the Psychiatry division in the office of the Surgeon General of the U.S. Army, led a
group of reformists trained in psychoanalysis (Cameron, 1989) that took a new approach
based on the development of occupational therapeutic techniques and other rehabilitation
methods. This new current of thought argued that if treated early, patients had a much higher
chance to recover (Armour, 1981). These psychiatrists became the most influential in the field
after the war and their experiences led to a shift in the understanding of mental health. It could
now apply to a wider variety of patients since the war had proven that anyone under stressful
circumstances could suffer from mental illness. The war helped unify the beliefs that
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environmental stress was an important contributor to mental maladjustment and that human
intervention could change psychological outcomes (Grob, 1991). This shift helped reduce the
stigma associated with mental illness because it was applicable to a greater sector of society.
However, it also played a role in the ultimate failure of community mental health services as it
neglected severely and chronically ill patients. The reform movement became a driving force
in the changing of public perception and government intervention in mental health services
policy. In 1947 the movement organized into the National Mental Health Foundation that
became a mainly educational society (Armour, 1981).
Public outrage regarding the state of mental health services led to a societal push
towards deinstitutionalization, which was the process of shifting the core of mental health
services from asylums to the community. The increasing concerns regarding civil rights of
patients led to the belief that community-based services would provide more humane
treatment (Lamb, 2000). After the war there was a sharp increase in media attention toward
the problems regarding asylums and mental health treatment. It was the first time that there
really was a co-operative understanding of millions of people in coming to grips with
Americas major health problem (Menninger, 1948, p. 362). The most significant impact on
the public came from the book The Shame of the States published in 1948 by the journalist
Albert Deutsch (Armour, 1981). Deutsh started unveiling to the public evidence of the abuse
suffered by patients in asylums after a nation-wide tour of mental institutions. It was not
Deutschs intention to attack the legitimacy of the asylum approach, but to show the need for
reform (Grob, 1991). Many other media outlets joined the movement and started criticizing
the situation of the mental health hospitals. This was seen in influential magazines such as
Life and even motion pictures like The Snake Pit (Grob, 1991). Highly controversial
treatments like lobotomy, coma inducement or electroshocks increased public outrage towards
asylums (Dain, 2000).
A turning point in the influence of the reformist movement came after the Mental
Health Act was introduced in 1946. This act founded the National Institute of Mental Health
which was a key player in the changes that the discipline experienced. According to its first
president, Robert Felix, it had three goals including promoting and aiding research in the
field, providing training of personnel, and helping states in the formation of clinics and
treatment centers (Armour, 1981). It promoted research and gave grants, as well as
establishing the reformist movement in the psychiatric departments of most universities and
colleges to stimulate training of the highly demanded mental health professionals (Morrissey,
1989). The reformist movement played a large role in increasing the importance of mental
health and the resources put into research and development of the field. Thus, World War II
triggering the creation of this reformist movement was a crucial factor in accelerating the
advancement of the field.
The introduction of antipsychotic drugs in 1954 was the final push for the reformist
movements ultimate success (Shorter, 1997). This allowed for the deinstitutionalization of
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mental health services. Policies and legislation started implementing the community-based
programs based on the new paradigms of psychiatry, culminating with President Kennedys
signing the Community Mental Health Centers Construction Act in 1963, referred to as the
bold new approach (Bell, 1989, p. 112). This plan intended the transfer of mental health
care from asylums to community centers. These centers were good for emergencies, short
term cases and intervention in crisis, but especially in later decades they demonstrated to have
flaws in aftercare and shelter, failing to help chronically and severely ill patients (Dowell,
1989).
The community mental health centers program ultimately failed as in its later stages it
was radicalized and disregarded the severely and chronically ill patients. They were left out in
the streets due to problems in coordination between services (Lamb, 2000), increasing
homelessness and public fear regarding mental health issues. However, this eventual failure
does not mean that the shift in the paradigms of psychiatry that these programs were based on
were not valid. This shift set a base that changed the understanding of mental health
permanently. Mental health passed from being related to outcasts and extremely stigmatized,
to being applicable to the normal person. The ideology had a benign phase from 1956 to
1965 when there was a renewal of active treatment and reductions in length of stay
(Morrissey, 1989). After this, several factors radicalized deinstitutionalization and drove it to
become a very significant societal failure at the end of the twentieth century.

World War two served as the principal factor that triggered the reform of mental health
services in the U.S. It set the scene for a series of events that led to the demise of the asylum
and the emergence of the community-based approach to mental health services. This shift not
only consisted on the fact that it was the first time that policy was introduced to care for
mental illness, but also on how the theories behind the reformation of the system changed the
social attitudes regarding mental health and had a profound effect in the development of the
field of psychiatry. World War II provided a final drive on the destruction of institutionalized
care by making the public and government aware of the importance of mental health. It also
pushed the already decrepit state of the asylums even further by reducing their funding and
ultimately made them subject to public outrage. Most importantly, it provided the appropriate
environment for the creation of a reformist movement that changed the approach to mental
illness treatment as a whole. The new policies experienced some failures and the reformists
theories were later criticized for being too idealistic and overlooking certain factors that later
caused other problems regarding the stigmatization of mental illness in relation to
homelessness and other social issues. However, they ultimately changed the perception of
mental health by popularizing it and removed great part of the stigma associated to it. Taking
mental health services back to the community made the public and government view
psychiatry and psychology in a less skeptical way. The response to mental health issues after

World War II from the government, the public and professionals, promoted an advancement of
the field that allowed it to match the status of other traditional medical disciplines.

REFERENCES

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England, and Sweden. Washington DC: University Press of America.

Bell, L.V. (1989). From the Asylum to the Community in U.S. Mental Health Care: A Historical
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Overview. In D. A. Rochefort (Ed.), Handbook on mental health policy in the United States
(pp. 89-120). Westport, Connecticut: Greenwood Publishing Group.

Cameron, J. M. (1989). A National Community Mental Health Program: Policy initiation and Progress.
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Shorter, E. (1997). A History of Psychiatry: From the era of the Asylum to the Age of Prozac. New
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