The Trap (TV series)

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/The_Trap_(TV_series)

The Trap: What Happened to Our Dream of Freedom
Title screen
Written by	Adam Curtis
Directed by	Adam Curtis
Country of origin	United Kingdom
Original language(s)	English
No. of series	1
No. of episodes	3
Production
Executive producer(s)	Stephen Lambert
Producer(s)	Adam Curtis Lucy Kelsall
Running time	180 mins (in three parts)
Production company(s)	BBC
Release
Original network	BBC Two
Picture format	16:9 1080i
Audio format	Stereo
Original release	11 March – 25 March 2007
Chronology
Preceded by	The Power of Nightmares (2004)
Followed by	All Watched Over by Machines of Loving Grace (2011)

The Trap: What Happened to Our Dream of Freedom is a BBC television documentary series by English filmmaker Adam Curtis, well known for other documentaries including The Century of the Self and The Power of Nightmares. It originally aired in the United Kingdom on BBC Two in March 2007. The series consists of three 60-minute programmes which explore the modern concept and definition of freedom, specifically, "how a simplistic model of human beings as self-seeking, almost robotic, creatures led to today's idea of freedom."

Production

The series was originally to be called Cold Cold Heart and was scheduled for broadcast in 2006. Although it is not known what caused the delay in transmission, nor the change in title, it is known that a DVD release of Curtis's previous series The Power of Nightmares had been delayed due to problems with copyright clearance due to the large quantity of archive material used in Curtis's montage technique.

Another documentary series (title unknown) based on very similar lines—"examining the world economy during the 1990s"—was to have been Curtis's first BBC TV project upon moving to the BBC's Current Affairs unit in 2002, shortly after producing Century of the Self.

Episodes

Part 1. "F**k You Buddy"

In part one, Curtis examines the rise of game theory during the Cold War and the way in which its mathematical models of human behaviour filtered into economic thought.

The programme traces the development of game theory, with particular reference to the work of John Nash (the mathematician portrayed in A Beautiful Mind), who believed that all humans are inherently suspicious and selfish creatures that strategize constantly. Building on his theory, Nash constructed logically consistent and mathematically verifiable models, for which he won the Bank of Sweden Prize in Economic Sciences, commonly referred to as the Nobel Prize in Economics. He invented system games that reflected his beliefs about human behaviour, including one he called 'Fuck You Buddy' (later published as "So Long Sucker"), in which the only way to win was to betray your playing partner, and it is from this game that the episode's title is taken. These games were internally coherent and worked correctly as long as the players obeyed the ground rules that they should behave selfishly and try to outwit their opponents, but when RAND's analysts tried the games on their own secretaries, they were surprised to find that instead of betraying each other, the secretaries cooperated every time. This did not, in the eyes of the analysts, discredit the models, but proved that the secretaries were unfit subjects. "This is in contrast to the proposed theoretical solution in which the two secretaries would have shared the amount g only, with the first secretary receiving m in addition. Upon inquiry, it developed that they had entered into the experiment with the prior agreement to share all proceeds equally!"

It was not known at the time that Nash was suffering from paranoid schizophrenia, and as a result, he was deeply suspicious of everyone around him—including his colleagues—and was convinced that many were involved in conspiracies against him. It was this mistaken belief that led to his view of people as a whole that formed the basis for his theories. Footage of an older and wiser Nash was shown in which he acknowledges that his paranoid views of other people at the time were false.

Curtis examines how game theory was used to create the US's nuclear strategy during the Cold War. Because no nuclear war occurred, it was believed that game theory had been correct in dictating the creation and maintenance of a massive American nuclear arsenal—because the Soviet Union had not attacked America with its nuclear weapons, the supposed deterrent must have worked. Game theory during the Cold War is a subject that Curtis examined in more detail in the To the Brink of Eternity part of his first series, Pandora's Box, and he reuses much of the same archive material in doing so.

Archive interview with R.D. Laing during episode 1

Another strand in the documentary is the work of R.D. Laing, whose work in psychiatry led him to model familial interactions using game theory. His conclusion was that humans are inherently selfish and shrewd and spontaneously generate stratagems during everyday interactions. Laing's theories became more developed when he concluded that some forms of mental illness were merely artificial labels, used by the state to suppress individual suffering. This belief became a staple tenet of counter-culture in the 1960s. Reference is made to an experiment run by one of Laing's students, David Rosenhan, in which bogus patients, self-presenting at a number of American psychiatric institutions, were falsely diagnosed as having mental disorders, while institutions, informed that they were to receive bogus patients, misidentified genuine patients as imposters. The results of the experiment were a disaster for American psychiatry, because they destroyed the idea that psychiatrists were a privileged elite that was genuinely able to diagnose, and therefore treat, mental illness.

Curtis credits the Rosenhan experiment with the inspiration to create a computer model of mental health. Input to the program consisted of answers to a questionnaire. Curtis describes a plan of the psychiatrists to test the computer model by issuing questionnaires to "hundreds of thousands" of randomly selected Americans. The diagnostic program identified over 50% of the ordinary people tested as suffering from some kind of mental disorder. According to Dr. Jerome Wakefield, who refers to the test as "these studies", the results it found were viewed as a general conclusion that "there is a hidden epidemic." Curtis and leaders in the psychiatric field never addressed whether the computer model was being tested or used without having been validated in any way, but rather used the model to justify vastly increasing the portion of the population they were treating.

In an interview, the economist James M. Buchanan decries the notion of the "public interest", asking what it is and suggesting that it consists purely of the self-interest of the governing bureaucrats. Buchanan also proposes that organisations should employ managers who are motivated only by money. He describes those who are motivated by other factors—such as job satisfaction or a sense of public duty—as "zealots". 

At the start of the 1970s, the theories of Laing and the models of Nash began to converge, leading to a popular belief that the state (a surrogate family) was purely and simply a mechanism of social control which calculatedly kept power out of the hands of the public. Curtis shows that it was this belief which allowed the theories of Hayek to look credible, and underpinned the free-market beliefs of Margaret Thatcher, who sincerely believed that by dismantling as much of the British state as possible—and placing former nationalised institutions into the hands of public shareholders—a form of social equilibrium could be reached. This was a return to Nash's work, in which he proved mathematically that if everyone pursued their own interests, a stable, yet perpetually dynamic, society would result. 

The episode ends with the suggestion that this mathematically modelled society is run on data—performance targets, quotas, statistics—and these figures, combined with the exaggerated belief in human selfishness, have created "a cage" for Western humans. The precise nature of the "cage" is to be discussed in part two.

Contributors

• John Nash, 1994 winner of the Nobel Memorial Prize in Economic Sciences
• Friedrich von Hayek, Nobel-winning economist and political philosopher
• James M. Buchanan, Nobel-winning economist famous for his work on public choice theory
• Professor Thomas Schelling, Nobel-winning economist and game theorist
• Robert Kavesh, government economist, 1950s
• Philip Mirowski, historian and philosopher of economics and politics
• Alain Enthoven, nuclear strategist at RAND Corporation, 1956–60
• R.D. Laing, psychiatrist
• Dr Morton Schatzman, psychiatrist and colleague of R. D. Laing
• Clancy Sigal, colleague of R. D. Laing
• Madsen Pirie, founder of the Adam Smith Institute
• Sir Antony Jay, co-author of BBC comedy series Yes Minister
• David Rosenhan, attendee of R. D. Laing's talks in the US; creator of the Rosenhan experiment
• Paul McHugh, psychiatrist-in-chief at Johns Hopkins Hospital
• Robert Spitzer, chair of the DSM-III task force
• Dr Jerome Wakefield, psychiatrist

Part 2. "The Lonely Robot"

Part two reiterated many of the ideas of the first part, but developed the theme that drugs such as Prozac and lists of psychological symptoms which might indicate anxiety or depression were being used to normalise behaviour and make humans behave more predictably, like machines. 

This was not presented as a conspiracy theory, but as a logical (although unpredicted) outcome of market-driven self-diagnosis by check-list based on symptoms, but not actual causes, discussed in part one. 

People with standard mood fluctuations diagnosed themselves as abnormal. They then presented themselves at psychiatrist's offices, fulfilled the diagnostic criteria without offering personal histories, and were medicated. The alleged result is that vast numbers of Western people have had their behaviour and mental activity modified by SSRIs without any strict medical necessity. 

The episode also showed a clip of a fight in a Yanomami village from the film The Ax Fight by Napoleon Chagnon and Tim Asch. According to Chagnon the fight is an example of the impact of kin selection on humans, since the people fighting chose sides on the basis of kinship. Curtis interviews Chagnon and puts to him the assertion of fellow anthropologist Brian Ferguson that much of the Yanamamo violence, particularly its intensity, was very strongly influenced by the presence of Westerners handing out goods which the tribesmen fought over; in this case the goods were highly prized and useful machetes. Chagnon, however, insists that his presence had had no influence whatsoever on the situation, citing the fact that similar fights happened when he wasn't present, which he also documented through informants. Curtis asked, "You don't think a film crew in the middle of a fight in a village has an effect?" Chagnon replied, "No, I don't," and immediately stopped the interview. 

Footage of Richard Dawkins propounding his gene-centered view of evolution is shown, with archive clips spanning two decades to emphasise how the severely reductionist ideas of programmed behaviour have slowly been absorbed by mainstream culture. (Later, however, the documentary gives evidence that cells are able to selectively replicate parts of DNA dependent on current needs. According to Curtis, such evidence detracts from the simplified economic models of human beings.) This brings Curtis back to the economic models of Hayek and the game theories of the Cold War. Curtis explains how, with the "robotic" description of mankind apparently validated by geneticists, the game theory systems gained even more currency with society's engineers. 

The programme describes how the Clinton administration gave in to market theorists in the US and how New Labour in the UK decided to measure everything it could by introducing such arbitrary and unmeasurable targets as:

• Reduction of hunger in Sub-Saharan Africa by 48%
• Reduction of global conflict by 6%

It also introduced a rural community vibrancy index in order to gauge the quality of life in Britain's villages and a birdsong index to measure the apparent decline of wildlife. 

In industry and public services, this way of thinking led to a plethora of targets, quotas and plans. It was meant to set workers free to achieve these targets in any way they chose. What the government did not realise was that the players, faced with impossible demands, would cheat.

Curtis describes how, in order to meet arbitrary targets:

• Lothian and Borders Police reclassified dozens of criminal offences as "suspicious occurrences" in order to keep them out of crime figures;
• Some NHS hospital trusts created the unofficial post of "The Hello Nurse," whose sole task it was to greet new arrivals in order to claim for statistical purposes that the patient had been "seen", even though no treatment or examination took place during the encounter;
• NHS managers took the wheels off trolleys and reclassified them as beds, while simultaneously reclassifying corridors as wards, in order to falsify Accident & Emergency waiting times statistics.

In a section called 'The Death of Social Mobility', Curtis describes how the theory of the free market was applied to education. In the UK, the introduction of school performance league tables was intended to give individual schools more power and autonomy, to enable them to compete for pupils, the theory being that it would motivate the worst-performing schools to improve; it was an attempt to move away from the rigid state control that had offered little choice to parents while failing to improve educational standards, and towards a culture of free choice and incentivisation, without going as far as privatising the schools. Following publication of the school league tables, wealthier parents moved into the catchment areas of the best schools, causing house prices in those areas to rise dramatically—ensuring that poor children were left with the worst-performing schools. This is just one aspect of a more rigidly stratified society which Curtis identifies in the way in which the incomes of working class Americans have actually fallen in real terms since the 1970s, while the incomes of the middle class have increased slightly, and those of the highest one percent of earners (the upper class) have quadrupled. Similarly, babies in the poorest areas in the UK are twice as likely to die in their first year as children from prosperous areas. 

Curtis ends part two with the observation that game theory and the free market model is now undergoing interrogation by economists who suspect a more irrational model of behaviour is appropriate and useful. In fact, in formal experiments the only people who behaved exactly according to the mathematical models created by game theory are economists themselves, and psychopaths.

Contributors

• James M. Buchanan, winner of Economics Prize for public choice theory
• Philip Mirowski, historian and philosopher of economics and politics
• Robert Rubin, economic adviser to Clinton
• Robert Reich, Secretary of Labor under Clinton (1993–1997)
• Thomas Frank, political journalist
• John Maynard Smith, geneticist (speaking in 1976)
• Napoleon Chagnon, anthropologist (filmed The Ax Fight in 1975)
• Richard Dawkins, popularizer of genetics (speaking in 1987)
• Paul McHugh, psychiatrist-in-chief of Johns Hopkins Hospital
• Robert Spitzer, chair of the DSM-III task force
• Dr Jerome Wakefield, psychiatrist
• Arthur Levitt, SEC Chair under Clinton (1993–2001)
• Itzhak Sharav, accounting professor
• Kevin Phillips, political analyst
• Brian Ferguson, anthropologist
• John Nash, winner of the Economics Prize for game theory

Part 3. "We Will Force You to Be Free"

Archive interview with Isaiah Berlin

 

The final part focusses on the concepts of positive and negative liberty introduced in the 1950s by Isaiah Berlin. Curtis briefly explains how negative liberty could be defined as freedom from coercion and positive liberty as the opportunity to strive to fulfil one's potential. Tony Blair had read Berlin's essays on the topic and wrote to him in the late 1990s, arguing that positive and negative liberty could be mutually compatible. As Berlin was on his deathbed at the time, Blair never got a reply.

The programme begins with a description of the Two Concepts of Liberty and Berlin's opinion that, since it lacked coercion, negative liberty was the safest of the two concepts. Curtis then explains how many political groups that sought their vision of freedom ended up using violence to achieve it. For example, the French revolutionaries wished to overthrow a monarchical system which they viewed as antithetical to freedom, but in doing so they ended up with the Reign of Terror. Similarly, the Bolshevik revolutionaries in Russia, who sought to overthrow the established order and replace it with a society in which everyone is equal, ended up creating a totalitarian regime which used violence to achieve its objectives.

Using violence, not simply as a means to achieve one's goals, but also as an expression of freedom from Western bourgeois norms, was an idea developed by Afro-Caribbean revolutionary Frantz Fanon. He developed it from the existentialist ideology of Jean-Paul Sartre, who argued that terrorism was a "terrible weapon, but the oppressed poor have no others." These views were expressed, for example, in the revolutionary film The Battle of Algiers. 

This part also explores how economic freedom had been used in Russia and the problems this had introduced. A set of policies known as "shock therapy" (also described in the 2007 book The Shock Doctrine by Naomi Klein) were brought in mainly by outsiders, which had the effect of destroying the social safety net that existed in most other western nations and Russia. In the latter, the sudden removal of the subsidies for basic goods caused their prices to rise enormously, making them hardly affordable to ordinary people. An economic crisis escalated during the 1990s and some people were paid in goods rather than money. Then-president Boris Yeltsin was accused by his parliamentary deputies of "economic genocide" due to the large numbers of people now too poor to eat. Yeltsin responded to this by removing parliament's power and becoming more autocratic. 

At the same time, many formerly state-owned industries were sold to private businesses, often at a fraction of their real value. Ordinary people, often in financial difficulties, would sell shares, which to them were worthless, for cash, without appreciating their true value. This culminated with the rise of the "Oligarchs"—super-rich businessmen who attributed their rise to the sell-offs of the 90s. It resulted in a polarisation of society into the poor and ultra-rich, and indirectly led to a more autocratic style of government under Vladimir Putin, which, while less free, promised to give people dignity and basic living requirements. 

There is a similar review of post-war Iraq, in which an even more extreme "shock therapy" was employed—the removal from government of all Ba'ath party employees and the introduction of economic models which followed the simplified economic model of human beings outlined in the first two parts—this resulted in the immediate disintegration of Iraqi society and the rise of two strongly autocratic insurgencies: one based on Sunni-Ba'athist ideals and another based on revolutionary Shi'a philosophies. 

Curtis also looks at the neoconservative agenda of the 1980s. Like Sartre, they argued that violence is sometimes necessary to achieve their goals, except they wished to spread what they described as democracy. Curtis quotes General Alexander Haig, then-US Secretary of State, as saying that, "Some things were worth fighting for." However, Curtis argues, although the version of society espoused by the neoconservatives made some concessions towards freedom, it did not offer true freedom. Although the neoconservatives, for example, forced the Augusto Pinochet regime in Chile and the Ferdinand Marcos regime in the Philippines to hold democratic elections, these transformations to democracy essentially replaced one elite with another, and the gap between those who have power and wealth, and those who have neither, remained; the freedom the change provided was therefore relatively narrow in concept. 

The neoconservatives wanted to change or overthrow the Sandinistas—a socialist group in Nicaragua—who were seen as tyrannical, destabilising, and a threat to US security; the US therefore supported anti-communist rebels known collectively as the Contras, who, Curtis states, carried out many violations of human rights, including the torture and murder of civilians. US Government financial support to the Contras had been banned by the US Congress, so other means were used to continue financing them, including the CIA allegedly providing aircraft for the rebels to fly cocaine into the United States, as well as the Iran–Contra affair in which the US illegally supplied weapons to the Iranian government, originally in exchange for assistance to gain the release of US prisoners in Lebanon, but also allegedly for cash which was then given to the Contras. Curtis uses this as another example of how the neoconservatives had fallen into the trap that Berlin had predicted: although they wanted to spread negative freedom, because they saw their ideology as an absolute truth they were able to justify using coercion and lies and also to support violence in order to perpetuate it. 

However such policies did not always result in the achievement of neoconservative aims and occasionally threw up genuine surprises. Curtis examines the Western-backed government of the Shah in Iran, and how the mixing of Sartre's positive libertarian ideals with Shia religious philosophy led to the revolution which overthrew it. Having previously been a meek philosophy of acceptance of the social order, in the minds of revolutionaries such as Ali Shariati and Ayatollah Khomeini, Revolutionary Shia Islam became a meaningful force to overthrow tyranny. 

The programme examines the government of Tony Blair and its role in achieving its vision of a stable society. In fact, argues Curtis, the Blair government had created the opposite of freedom, in that the type of liberty it had engendered wholly lacked any kind of meaning. Its military intervention in Iraq had provoked terrorist actions in the UK and these terrorist actions were in turn used to justify restrictions on liberty. 

In essence, the programme suggests that following the path of negative liberty to its logical conclusions, as governments have done in the West for the past 50 years, results in a society without meaning populated only by selfish automatons, and that there was some value in positive liberty in that it allowed people to strive to better themselves. 

The closing minutes directly state that if Western humans are ever to find their way out of the "trap" described in the series, they would have to realise that Isaiah Berlin was wrong, and that not all attempts to change the world for the better necessarily lead to tyranny.

Contributors

• Isaiah Berlin, political philosopher
• Kenneth Clark, historian, presenter of BBC TV series Civilisation
• Malcolm Muggeridge, British journalist
• Stuart Hall, cultural historian
• Jean-Paul Sartre, existentialist philosopher
• Frantz Fanon, psychoanalyst, revolutionary
• Jim Howard, field director, OXFAM
• Michael Ledeen, advocate of US regime change policy
• Alexander Haig, first US Secretary of State under Ronald Reagan
• Samuel P. Huntington, US political scientist
• Elliott Abrams, Assistant US Secretary of State 1981–1989
• Robert Parry, Press Association reporter in Nicaragua in the 1980s
• Francis Fukuyama, political philosopher
• Jeffrey Sachs, US economist
• Yevgeny Kiselyov, general director of NTV, Russian TV station

Reception

Economist Max Steuer criticised the documentary for "romanticis[ing] the past while misrepresenting the ideas it purports to explain"; for example, Curtis suggests that the work of Buchanan and others on public choice theory made Government officials wicked and selfish, rather than simply providing an account of what happened.

In the New Statesman, Rachel Cooke argued that the series doesn't make a coherent argument. She said that while she was glad Adam Curtis made provocative documentaries, he was as much of a propagandist as those he opposes.

While commending the series, Radio Times stated that The Trap's subject matter was not ideal for its 21:00 Sunday timeslot on the minority BBC Two. This placed The Trap against Castaway 2007 on BBC One, the drama Fallen Angel, the first two episodes in a series of high-profile Jane Austen adaptations on ITV1, and the sixth season of 24 on Sky One. However, the series had a consistent share of the viewing audience throughout its original run:

1. "Fuck You Buddy" (11 March 2007): ~ 1.4 million viewers; 6% audience share
2. "The Lonely Robot" (18 March 2007): ~ 1.3 million viewers; 6% audience share
3. "We Will Force You to Be Free" (25 March 2007) ~ 1.3 million viewers; 6% audience share

Featured music

• "The Godfathers at Home" from The Godfather Part II soundtrack (opening title)
• "Intermezzo" from The Karelia Suite by Jean Sibelius (opening title, episode one; also in episode three)
• "Return to Hot Chicken", from the album I Can Hear the Heart Beating as One by Yo La Tengo
• "Nowhere Near" from the album Painful by Yo La Tengo
• "On Some Faraway Beach", from the album Here Come the Warm Jets by Brian Eno
• "Age of Consent", from the album Power, Corruption & Lies by New Order
• "Assault on Precinct 13 (Main Title)" from the Assault on Precinct 13 soundtrack by John Carpenter
• "Scene d'Amour", "Interlude", "The Reunion", "The Match Box" and other movements from the Vertigo and North by Northwest scores by Bernard Herrmann
• "Cosmonaute" from the album Monokini by Stereo Total
• "Is That All There Is?" by Peggy Lee
• "Becalmed" from the album Another Green World by Brian Eno
• "Taking Tiger Mountain" from Taking Tiger Mountain by Strategy by Brian Eno
• "The Thing (Main Title)" from The Thing score by Ennio Morricone
• "Profondamente, Nel Mostro - Part 1" from Il Mostro score by Ennio Morricone, used near the end of the first and the third (Yeltsin part) episode.
• "Contest Winners" from the Carrie score by Pino Donaggio
• "Great Release" from LCD Soundsystem by LCD Soundsystem
• "La Marseillaise" (end credits, episode three)
• The Gadfly, Op. 97 "Romance" by Dmitri Shostakovich
• "Theme from Starman" (1984 film by John Carpenter) by Jack Nitzsche
• "The Aquarium" from "Le Carnaval des Animaux" by Camille Saint-Saëns
• "Theme from Tragedy of a Ridiculous Man" (1981 film by Bernardo Bertolucci) by Ennio Morricone

From the motion picture Carrie: "For the Last Time We'll Pray" by Pino Donaggio.

Rosenhan experiment

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Rosenhan_experiment

The main building of St Elizabeths Hospital (1996), located in Washington, D.C., now boarded up and abandoned, was one of the sites of the Rosenhan experiment

 

The Rosenhan experiment or Thud experiment was conducted to determine the validity of psychiatric diagnosis. The experimenters feigned hallucinations to enter psychiatric hospitals, and acted normally afterwards. They were diagnosed with psychiatric disorders and were given antipsychotic drugs. The study was conducted by psychologist David Rosenhan, a Stanford University professor, and published by the journal Science in 1973 under the title "On being sane in insane places". It is considered an important and influential criticism of psychiatric diagnosis.

Rosenhan's study was done in eight parts. The first part involved the use of healthy associates or "pseudopatients" (three women and five men, including Rosenhan himself) who briefly feigned auditory hallucinations in an attempt to gain admission to 12 psychiatric hospitals in five states in the United States. All were admitted and diagnosed with psychiatric disorders. After admission, the pseudopatients acted normally and told staff that they felt fine and had no longer experienced any additional hallucinations. All were forced to admit to having a mental illness and had to agree to take antipsychotic drugs as a condition of their release. The average time that the patients spent in the hospital was 19 days. All but one were diagnosed with schizophrenia "in remission" before their release. 

The second part of his study involved an offended hospital administration challenging Rosenhan to send pseudopatients to its facility, whom its staff would then detect. Rosenhan agreed and in the following weeks out of 250 new patients the staff identified 41 as potential pseudopatients, with 2 of these receiving suspicion from at least one psychiatrist and one other staff member. In fact, Rosenhan had sent no pseudopatients to the hospital. 

While listening to a lecture by R. D. Laing, who was associated with the anti-psychiatry movement, Rosenhan conceived of the experiment as a way to test the reliability of psychiatric diagnoses. The study concluded "it is clear that we cannot distinguish the sane from the insane in psychiatric hospitals" and also illustrated the dangers of dehumanization and labeling in psychiatric institutions. It suggested that the use of community mental health facilities which concentrated on specific problems and behaviors rather than psychiatric labels might be a solution, and recommended education to make psychiatric workers more aware of the social psychology of their facilities.

In a 2019 popular book on Rosenhan by author Susannah Cahalan, The Great Pretender, the veracity and validity of the Rosenhan experiment has been questioned.

Pseudopatient experiment

Rosenhan himself and seven mentally healthy associates, called "pseudopatients", attempted to gain admission to psychiatric hospitals by calling for an appointment and feigning auditory hallucinations. The hospital staff were not informed of the experiment. The pseudopatients included a psychology graduate student in his twenties, three psychologists, a pediatrician, a psychiatrist, a painter, and a housewife. None had a history of mental illness. Pseudopatients used pseudonyms, and those who worked in the mental health field were given false jobs in a different sector to avoid invoking any special treatment or scrutiny. Apart from giving false names and employment details, further biographical details were truthfully reported.

During their initial psychiatric assessment, the pseudopatients claimed to be hearing voices of the same sex as the patient which were often unclear, but which seemed to pronounce the words "empty", "hollow", or "thud", and nothing else. These words were chosen as they vaguely suggest some sort of existential crisis and for the lack of any published literature referencing them as psychotic symptoms. No other psychiatric symptoms were claimed. If admitted, the pseudopatients were instructed to "act normally", reporting that they felt fine and no longer heard voices. Hospital records obtained after the experiment indicate that all pseudopatients were characterized as friendly and cooperative by staff.

All were admitted, to 12 psychiatric hospitals across the United States, including rundown and underfunded public hospitals in rural areas, urban university-run hospitals with excellent reputations, and one expensive private hospital. Though presented with identical symptoms, seven were diagnosed with schizophrenia at public hospitals, and one with manic-depressive psychosis, a more optimistic diagnosis with better clinical outcomes, at the private hospital. Their stays ranged from 7 to 52 days, and the average was 19 days. All were discharged with a diagnosis of schizophrenia "in remission", which Rosenhan considered as evidence that mental illness is perceived as an irreversible condition creating a lifelong stigma rather than a curable illness.

Despite constantly and openly taking extensive notes on the behavior of the staff and other patients, none of the pseudopatients were identified as impostors by the hospital staff, although many of the other psychiatric patients seemed to be able to correctly identify them as impostors. In the first three hospitalizations, 35 of the total of 118 patients expressed a suspicion that the pseudopatients were sane, with some suggesting that the patients were researchers or journalists investigating the hospital. Hospital notes indicated that staff interpreted much of the pseudopatients' behavior in terms of mental illness. For example, one nurse labeled the note-taking of one pseudopatient as "writing behavior" and considered it pathological. The patients' normal biographies were recast in hospital records along the lines of what was expected of schizophrenics by the then-dominant theories of its cause.

The experiment required the pseudopatients to get out of the hospital on their own by getting the hospital to release them, though a lawyer was retained to be on call for emergencies when it became clear that the pseudopatients would not ever be voluntarily released on short notice. Once admitted and diagnosed, the pseudopatients were not able to obtain their release until they agreed with the psychiatrists that they were mentally ill and began taking antipsychotic medications, which they flushed down the toilet. No staff member reported that the pseudopatients were flushing their medication down the toilets. 

Rosenhan and the other pseudopatients reported an overwhelming sense of dehumanization, severe invasion of privacy, and boredom while hospitalized. Their possessions were searched randomly, and they were sometimes observed while using the toilet. They reported that though the staff seemed to be well-meaning, they generally objectified and dehumanized the patients, often discussing patients at length in their presence as though they were not there, and avoiding direct interaction with patients except as strictly necessary to perform official duties. Some attendants were prone to verbal and physical abuse of patients when other staff were not present. A group of bored patients waiting outside the cafeteria for lunch early were said by a doctor to his students to be experiencing "oral-acquisitive" psychiatric symptoms. Contact with doctors averaged 6.8 minutes per day.

Non-existent impostor experiment

For this experiment, Rosenhan used a well-known research and teaching hospital, whose staff had heard of the results of the initial study but claimed that similar errors could not be made at their institution. Rosenhan arranged with them that during a three-month period, one or more pseudopatients would attempt to gain admission and the staff would rate every incoming patient as to the likelihood they were an impostor. Out of 193 patients, 41 were considered to be impostors and a further 42 were considered suspect. In reality, Rosenhan had sent no pseudopatients; all patients suspected as impostors by the hospital staff were ordinary patients. This led to a conclusion that "any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one".

Impact and controversy

Rosenhan published his findings in Science, in which he criticized the reliability of psychiatric diagnosis and the disempowering and demeaning nature of patient care experienced by the associates in the study. In addition, he described his work in a variety of news appearances, including to the BBC:

I told friends, I told my family: "I can get out when I can get out. That's all. I'll be there for a couple of days and I'll get out." Nobody knew I'd be there for two months ... The only way out was to point out that they're [the psychiatrists] correct. They had said I was insane, "I am insane; but I am getting better." That was an affirmation of their view of me.

The article generated an explosion of controversy. The experiment is argued to have "accelerated the movement to reform mental institutions and to deinstitutionalize as many mental patients as possible".

Many respondents to the publication defended psychiatry, arguing that as psychiatric diagnosis relies largely on the patient's report of their experiences, faking their presence no more demonstrates problems with psychiatric diagnosis than lying about other medical symptoms. In this vein, psychiatrist Robert Spitzer quoted Seymour S. Kety in a 1975 criticism of Rosenhan's study:

If I were to drink a quart of blood and, concealing what I had done, come to the emergency room of any hospital vomiting blood, the behavior of the staff would be quite predictable. If they labeled and treated me as having a bleeding peptic ulcer, I doubt that I could argue convincingly that medical science does not know how to diagnose that condition.

Kety also argued that psychiatrists should not necessarily be expected to assume that a patient is pretending to have mental illness, thus the study lacked realism. Rosenhan called this the "experimenter effect" or "expectation bias", something indicative of the problems he uncovered rather than a problem in his methodology. Others have pointed out that a competent psychiatrist or psychologist would be aware of the possibility of transient symptoms and would be willing to consider other explanations for a seemingly brief symptom, than the lifelong organic mental illness they instead insisted upon being acknowledged by the patient.

In a 2019 popular book on Rosenhan by author Susannah Cahalan, The Great Pretender, the veracity and validity of the Rosenhan experiment has been questioned; Cahalan argues that Rosenhan never published further work on the experiment's data, nor did he deliver on a book on it that he had promised. Moreover, after half a century, she could not find experiment's subjects, save two—Rosenhan himself, dead since then, and another volunteer, whose testimony was allegedly inconsistent with Rosenhan's statements. Susannah concluded that she cannot be completely certain that Rosenhan cheated, despite titling her book 'The Great Pretender'.

Related experiments

In 1887 American investigative journalist Nellie Bly feigned symptoms of mental illness to gain admission to a lunatic asylum and report on the terrible conditions therein. The results were published as Ten Days in a Mad-House.

In 1968 Maurice K. Temerlin split 25 psychiatrists into two groups and had them listen to an actor portraying a character of normal mental health. One group was told that the actor "was a very interesting man because he looked neurotic, but actually was quite psychotic" while the other was told nothing. Sixty percent of the former group diagnosed psychoses, most often schizophrenia, while none of the control group did so.

In 1988, Loring and Powell gave 290 psychiatrists a transcript of a patient interview and told half of them that the patient was black and the other half white; they concluded of the results that "clinicians appear to ascribe violence, suspiciousness, and dangerousness to black clients even though the case studies are the same as the case studies for the white clients."

In 2004, psychologist Lauren Slater claimed to have conducted an experiment very similar to Rosenhan's for her book Opening Skinner's Box. Slater wrote that she had presented herself at 9 psychiatric emergency rooms with auditory hallucinations, resulting in being diagnosed "almost every time" with psychotic depression. However, when challenged to provide evidence of actually conducting her experiment, she could not. The serious methodologic and other concerns regarding Slater's work appeared as a series of responses to a journal report, in the same journal.

In popular media

In 2008, the BBC's Horizon science program performed a somewhat related experiment over two episodes entitled "How Mad Are You?". The experiment involved ten subjects, five with previously diagnosed mental health conditions, and five with no such diagnosis. They were observed by three experts in mental health diagnoses and their challenge was to identify the five with mental health problems solely from their behavior, without speaking to the subjects or learning anything of their histories. The experts correctly diagnosed two of the ten patients, misdiagnosed one patient, and incorrectly identified two healthy patients as having mental health problems. Unlike the other experiments listed here, however, the aim of this journalistic exercise was not to criticize the diagnostic process, but to minimize the stigmatization of the mentally ill. It aimed to illustrate that people with a previous diagnosis of a mental illness could live normal lives with their health problems not obvious to observers from their behavior.

Deinstitutionalisation

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Deinstitutionalisation

The former St Elizabeth's Hospital in 2006, closed and boarded up. Located in Washington D.C., the hospital had been one of the sites of the Rosenhan experiment in the 1970s.

 

Deinstitutionalisation (or deinstitutionalization) is the process of replacing long-stay psychiatric hospitals with less isolated community mental health services for those diagnosed with a mental disorder or developmental disability. In the late 20th century, it led to the closure of many psychiatric hospitals, as patients were increasingly cared for at home, in halfway houses and clinics, and in regular hospitals.

Deinstitutionalisation works in two ways. The first focuses on reducing the population size of mental institutions by releasing patients, shortening stays, and reducing both admissions and readmission rates. The second focuses on reforming psychiatric care to reduce (or avoid encouraging) feelings of dependency, hopelessness and other behaviors that make it hard for patients to adjust to a life outside of care. 

The modern deinstitutionalisation movement was made possible by the discovery of psychiatric drugs in the mid-20th century, which could manage psychotic episodes and reduced the need for patients to be confined and restrained. Another major impetus was a series of socio-political movements that campaigned for patient freedom. Lastly, there were financial imperatives, with many governments also viewing it as a way to save costs. 

The movement to reduce institutionalisation was met with wide acceptance in Western countries, though its effects have been the subject of many debates. Critics of the policy include defenders of the previous policies as well as those who believe the reforms did not go far enough to provide freedom to patients.

History

19th century

Vienna's Narrenturm—German for "fools' tower"—was one of the earliest buildings specifically designed for mentally ill people. It was built in 1784.

 

The 19th century saw a large expansion in the number and size of asylums in Western industrialised countries. In contrast to the prison-like asylums of old, these were designed to be comfortable places where patients could live and be treated, in keeping with the movement towards "moral treatment". In spite of these ideals, they became overstretched, non-therapeutic, isolated in location, and neglectful of patients.

20th century

By the beginning of the 20th century, increasing admissions had resulted in serious overcrowding, causing many problems for psychiatric institutions. Funding was often cut, especially during periods of economic decline and wartime. Asylums became notorious for poor living conditions, lack of hygiene, overcrowding, ill-treatment, and abuse of patients; many patients starved to death. The first community-based alternatives were suggested and tentatively implemented in the 1920s and 1930s, although asylum numbers continued to increase up to the 1950s.

Origins of the modern movement

The movement for deinstitutionalisation moved to the forefront in various countries during the 1950s and 1960s with the advent of chlorpromazine and other antipsychotic drugs. 

A key text in the development of deinstitutionalisation was Asylums: Essays on the Social Situation of Mental Patients and Other Inmates, a 1961 book by sociologist Erving Goffman. The book is one of the first sociological examinations of the social situation of mental patients, the hospital. Based on his participant observation field work, the book details Goffman's theory of the "total institution" (principally in the example he gives, as the title of the book indicates, mental institutions) and the process by which it takes efforts to maintain predictable and regular behavior on the part of both "guard" and "captor," suggesting that many of the features of such institutions serve the ritual function of ensuring that both classes of people know their function and social role, in other words of "institutionalizing" them.

Franco Basaglia, a leading Italian psychiatrist who inspired and was the architect of the psychiatric reform in Italy, also defined mental hospital as an oppressive, locked and total institution in which prison-like, punitive rules are applied, in order to gradually eliminate its own contents, and patients, doctors and nurses are all subjected (at different levels) to the same process of institutionalism. Other critics went further and campaigned against all involuntary psychiatric treatment. In 1970, Goffman worked with Thomas Szasz and George Alexander to found the American Association for the Abolition of Involuntary Mental Hospitalisation (AAAIMH), who proposed abolishing all involuntary psychiatric intervention, particularly involuntary commitment, against individuals. The association provided legal help to psychiatric patients and published a journal, The Abolitionist, until it was dissolved in 1980.

Reform

The prevailing public arguments, time of onset, and pace of reforms varied by country. Leon Eisenberg lists three key factors that led to deinstitutionalisation gaining support. The first were socio-political campaigns for the better treatment of patients. Some of these were spurred on by institutional abuse scandals in the 1960s and 1970s, such as Willowbrook State School in the United States and Ely Hospital in the United Kingdom. Other incentives were that new psychiatric medications made it more feasible to release people into the community, and the argument that community services would be cheaper. Mental health professionals, public officials, families, advocacy groups, public citizens, and unions held differing views on deinstitutionalisation.

However, the 20th Century marked the development of the first community services designed specifically to divert deinstitutionalization and to develop the first conversions from institutional, governmental systems to community majority systems (governmental-NGO-For Profit). These services are so common throughout the world (e.g., individual and family support services, groups homes, community and supportive living, foster care and personal care homes, community residences, community mental health offices, supported housing) that they are often "delinked" from the term deinstitutionalization. Common historical figures in deinstitutionalization in the US include Geraldo Rivera, Robert Williams, Burton Blatt, Gunnar Dybwad, Michael Kennedy, Frank Laski, Steven J. Taylor, Douglas P. Biklen, David Braddock, Robert Bogdan and K. C. Lakin. in the fields of "intellectual disabilities" (e.g., amicus curae, Arc-US to the US Supreme Court; US state consent decrees). 

Community organizing and development regarding the fields of mental health, traumatic brain injury, aging (nursing facilities) and children's institutions/private residential schools represent other forms of diversion and "community re-entry". Paul Carling's book, Return to the Community: Building Support Systems for People with Psychiatric Disabilities describes mental health planning and services in that regard, including for addressing the health and personal effects of "long term institutionalization".  and the psychiatric field continued to research whether "hospitals" (e.g., forced involuntary care in a state institution; voluntary, private admissions) or community living was better.  US states have made substantial investments in the community, and similar to Canada, shifted some but not all institutional funds to the community sectors as deinstitutionalization. For example, NYS Education, Health and Social Services Laws identify mental health personnel in the state of New York, and the two term Obama Presidency in the US created a high-level Office of Social and Behavioral Services. 

The 20th Century marked the growth in a class of deinstitutionalization and community researchers in the US and world, including a class of university women. These women follow university education on social control and the myths of deinstitutionalization, including common forms of transinstitutionalization such as transfers to prison systems in the 21st Century, "budget realignments", and the new subterfuge of community data reporting.

Consequences

Community services that developed include supportive housing with full or partial supervision and specialised teams (such as assertive community treatment and early intervention teams). Costs have been reported as generally equivalent to inpatient hospitalisation, even lower in some cases (depending on how well or poorly funded the community alternatives are). Although deinstitutionalisation has been positive for the majority of patients, it also has shortcomings. 

Criticism of deinstitutionalisation takes two forms. Some, like E. Fuller Torrey, defend the use of psychiatric institutions and conclude that deinstitutionalisation was a move in the wrong direction. Others, such as Walid Fakhoury and Stefan Priebe, argue that it was an unsuccessful move in the right direction, suggesting that modern day society faces the problem of "reinstitutionalisation". While coming from opposite viewpoints, both sets of critics argue that the policy left many patients homeless or in prison. Leon Eisenberg has argued that deinstitutionalisation was generally positive for patients, while noting that some were left homeless or without care.

Misconceptions

There is a common perception by the public and media that people with mental disorders are more likely to be dangerous and violent if released into the community. However, a large 1998 study in Archives of General Psychiatry suggested that discharged psychiatric patients without substance abuse symptoms are no more likely to commit violence than others without substance abuse symptoms in their neighborhoods, which were usually economically deprived and high in substance abuse and crime. The study also reported that a higher proportion of the patients than of the others in the neighborhoods reported symptoms of substance abuse.

Findings on violence committed by those with mental disorders in the community have been inconsistent and related to numerous factors; a higher rate of more serious offences such as homicide have sometimes been found but, despite high-profile homicide cases, the evidence suggests this has not been increased by deinstitutionalisation. The aggression and violence that does occur, in either direction, is usually within family settings rather than between strangers.

Adequacy of treatment and support

Common criticisms of the new community services are that they have been uncoordinated, underfunded and unable to meet complex needs. Problems with coordination arose because care was being provided by multiple for-profit businesses, non-profit organizations and multiple levels of government.

Torrey has opposed deinstitutionalisation in principle, arguing that people with mental illness will be resistant to medical help due to the nature of their conditions. These views have made him a controversial figure in psychiatry. He believes that reducing psychiatrists' powers to use involuntary commitment led to many patients losing out on treatment, and that many who would have previously lived in institutions are now homeless or in prison.

Other critics argue that deinstitutionalisation had laudable goals, but some patients lost out on care due to problems in the execution stage. In a 1998 study of the effects of deinstitutionalisation in the United Kingdom, Means and Smith argue that the program had some successes, such as increasing the participation of volunteers in mental healthcare, but that it was underfunded and let down by a lack of coordination between the health service and social services.

Transinstitutionalisation

Some mental health academics and campaigners have argued that deinstitutionalisation was well-intentioned for trying to make patients less dependent on psychiatric care, but in practice patients were still left being dependent on the support of a mental healthcare system, a phenomenon known as "reinstitutionalisation" or "transinstitutionalisation".

The argument is that community services can leave the mentally ill in a state of social isolation (even if it is not physical isolation), frequently meeting other service users but having little contact with the rest of the public community. Fakhoury and Priebe said that instead of "community psychiatry", reforms established a "psychiatric community". Julie Racino argues that having a closed social circle like this can limit opportunities for mentally ill people to integrate with the wider society, such as personal assistance services.

Thomas Szasz, a longtime opponent of involuntary psychiatric treatment, argued that the reforms never addressed the aspects of psychiatry that he objected to, particularly his belief that mental illnesses are not true illnesses but medicalized social and personal problems.

Medication

There was an increase in prescriptions of psychiatric medication in the years following deinstitutionalization. Although most of these drugs had been discovered in the years before, deinstitutionalisation made it far cheaper to care for a mental health patient and increased the profitability of the drugs. Some researchers argue that this created economic incentives to increase the frequency of psychiatric diagnosis (and related diagnoses, such as ADHD in children) that did not happen in the era of costly hospitalized psychiatry.

In most countries (except some countries that are either in extreme poverty or are hindered from importing psychiatric drugs by their customs regulations), more than 10% of the population are now on some form of psychiatric medicine. This increases to more than 15% in some countries such as the United Kingdom. A 2012 study by Kales, Pierce and Greenblatt argued that these medicines were being overprescribed.

Victimisation

Moves to community living and services have led to various concerns and fears, from both the individuals themselves and other members of the community. Over a quarter of individuals accessing community mental health services in a US inner-city area are victims of at least one violent crime per year, a proportion eleven times higher than the inner-city average. The elevated victim rate holds for every category of crime, including rape/sexual assault, other violent assaults, and personal and property theft. Victimisation rates are similar to those with developmental disabilities.

Worldwide

Asia

Hong Kong

In Hong Kong, a number of residential care services such as halfway houses, long-stay care homes, supported hostels are provided for the discharged patients. In addition, community support services such as rehabilitation day services and mental health care have been launched to facilitate the patients' re-integration into the community.

Japan

Unlike most developed countries, Japan has not followed a program of deinstitutionalisation. The number of hospital beds has risen steadily over the last few decades. Physical restraints are used far more often. In 2014, more than 10,000 people were restrained–the highest ever recorded, and more than double the number a decade earlier. In 2018, the Japanese Ministry of Health introduced revised guidelines that placed more restrictions against the use of restraints.

Africa

Uganda has one psychiatric hospital. There are only 40 psychiatrists in Uganda. The World Health Organisation estimates that 90% of mentally ill people here never get treatment. 

Australia and Oceania

New Zealand

New Zealand established a reconciliation initiative in 2005 to address the ongoing compensation payouts to ex-patients of state-run mental institutions in the 1970s to 1990s. A number of grievances were heard, including: poor reasons for admissions; unsanitary and overcrowded conditions; lack of communication to patients and family members; physical violence and sexual misconduct and abuse; inadequate mechanisms for dealing with complaints; pressures and difficulties for staff, within an authoritarian hierarchy based on containment; fear and humiliation in the misuse of seclusion; over-use and abuse of ECT, psychiatric medications, and other treatments as punishments, including group therapy, with continued adverse effects; lack of support on discharge; interrupted lives and lost potential; and continued stigma, prejudice, and emotional distress and trauma. 

There were some references to instances of helpful aspects or kindnesses despite the system. Participants were offered counselling to help them deal with their experiences, along with advice on their rights, including access to records and legal redress.

Europe

In some countries where deinstitutionalisation has occurred, "re-institutionalisation", or relocation to different institutions, has begun, as evidenced by increases in the number of supported housing facilities, forensic psychiatric beds, and the growing prison population.

Some developing European countries still rely on asylums.

Italy

Italy was the first country to begin the deinstitutionalisation of mental health care and to develop a community-based psychiatric system. The Italian system served as a model of effective service and paved the way for deinstitutionalisation of mental patients. Since the late 1960s, the Italian physician Giorgio Antonucci questioned the basis itself of psychiatry. After working with Edelweiss Cotti in 1968 at the Centro di Relazioni Umane in Cividale del Friuli – an open ward created as an alternative to the psychiatric hospital – from 1973 to 1996 Antonucci worked on the dismantling of the psychiatric hospitals Osservanza and Luigi Lolli of Imola and the liberation – and restitution to life – of the people there secluded. In 1978, the Basaglia Law had started Italian psychiatric reform that resulted in the end of the Italian state mental hospital system in 1998.

The reform was focused on the gradual dismantlement of psychiatric hospitals, which required an effective community mental health service. The object of community care was to reverse the long-accepted practice of isolating the mentally ill in large institutions and to promote their integration in a socially stimulating environment, while avoiding subjecting them to excessive social pressures.

The work of Giorgio Antonucci, instead of changing the form of commitment from the mental hospital to other forms of coercion, questions the basis of psychiatry, affirming that mental hospitals are the essence of psychiatry and rejecting any possible reform of psychiatry, that must be completely eliminated.

United Kingdom

The water tower of Park Prewett Hospital in Basingstoke, Hampshire. The hospital was redeveloped into a housing estate after its closure in 1997.

In the United Kingdom, the trend towards deinstitutionalisation began in the 1950s. At the time, 0.4% of the population of England were housed in asylums. The government of Harold Macmillan sponsored the Mental Health Act 1959, which removed the distinction between psychiatric hospitals and other types of hospitals. Enoch Powell, the Minister of Health in the early 1960s, criticized psychiatric institutions in his 1961 "Water Tower" speech and called for most of the care to be transferred to general hospitals and the community. The campaigns of Barbara Robb and several scandals involving mistreatment at asylums (notably Ely Hospital) furthered the campaign. The Ely Hospital scandal led to an inquiry led by Brian Abel-Smith and a 1971 white paper that recommended further reform.

The policy of deinstitutionalisation came to be known as Care in the Community at the time it was taken up by the government of Margaret Thatcher. Large-scale closures of the old asylums began in the 1980s. By 2015, none remained.

North America

United States

President John F. Kennedy signs the Community Mental Health Act.

 

The United States has experienced two main waves of deinstitutionalisation. The first wave began in the 1950s and targeted people with mental illness. The second wave began roughly 15 years later and focused on individuals who had been diagnosed with a developmental disability. Loren Mosher argues that deinstitutionalisation fully began in the 1970s and was due to financial incentives like SSI and Social Security Disability, rather than after the earlier introduction of psychiatric drugs.

The most important factors that led to deinstitutionalisation were changing public attitudes to mental health and mental hospitals, the introduction of psychiatric drugs and individual states' desires to reduce costs from mental hospitals. The federal government offered financial incentives to the states to achieve this goal. Stroman pinpoints World War II as the point when attitudes began to change. In 1946, Life magazine published one of the first exposés of the shortcomings of mental illness treatment. Also in 1946, Congress passed the National Mental Health Act of 1946, which created the National Institute of Mental Health (NIMH). NIMH was pivotal in funding research for the developing mental health field.

President John F. Kennedy had a special interest in the issue of mental health because his sister, Rosemary, had incurred brain damage after being lobotomised at the age of 23. His administration sponsored the successful passage of the Community Mental Health Act, one of the most important laws that led to deinstitutionalization. The movement continued to gain momentum during the Civil Rights Movement. The 1965 amendments to Social Security shifted about 50% of the mental health care costs from states to the federal government, motivating state governments to promote deinstitutionalization. The 1970s saw the founding of several advocacy groups, including Liberation of Mental Patients, Project Release, Insane Liberation Front, and the National Alliance on Mental Illness (NAMI).

The lawsuits these activist groups filed led to some key court rulings in the 1970s that increased the rights of patients. In 1973, a federal district court ruled in Souder v. Brennan that whenever patients in mental health institutions performed activity that conferred an economic benefit to an institution, they had to be considered employees and paid the minimum wage required by the Fair Labor Standards Act of 1938. Following this ruling, institutional peonage was outlawed. In the 1975 ruling O'Connor v. Donaldson, the U.S. Supreme Court restricted the rights of states to incarcerate someone who was not violent. This was followed up with the 1978 ruling Addington v. Texas, further restricting states from confining anyone involuntarily for mental illness. In 1975, the United States Court of Appeals for the First Circuit ruled in favour of the Mental Patient's Liberation Front in Rogers v. Okin, establishing the right of a patient to refuse treatment. Later reforms included the Mental Health Parity Act, which required health insurers to give mental health patients equal coverage. 

Other factors included scandals. A 1972 television broadcast exposed the abuse and neglect of 5,000 patients at the Willowbrook State School in Staten Island, New York. The Rosenhan's experiment in 1973 caused several psychiatric hospitals to fail to notice fake patients who showed no symptoms once they were institutionalized. The pitfalls of institutionalization were dramatized in an award-winning 1975 film, One Flew Over the Cuckoo's Nest.

In 1955, for every 100,000 US citizens there were 340 psychiatric hospital beds. In 2005 that number had diminished to 17 per 100,000.

South America

In several South American countries, such as in Argentina, the total number of beds in asylum-type institutions has decreased, replaced by psychiatric inpatient units in general hospitals and other local settings.

In Brazil, there are 6003 psychiatrists, 18,763 psychologists, 1985 social workers, 3119 nurses and 3589 occupational therapists working for the Unified Health System (SUS). At primary care level, there are 104,789 doctors, 184, 437 nurses and nurse technicians and 210,887 health agents. The number of psychiatrists is roughly 5 per 100,000 inhabitants in the Southeast region, and the Northeast region has less than 1 psychiatrist per 100,000 inhabitants. The number of psychiatric nurses is insufficient in all geographical areas, and psychologists outnumber other mental health professionals in all regions of the country. The rate of beds in psychiatric hospitals in the country is 27.17 beds per 100,000 inhabitants. The rate of patients in psychiatric hospitals is 119 per 100,000 inhabitants. The average length of stay in mental hospitals is 65.29 days.