Philanthropy, Nonprofits, and Deinstitutionalization of the Psychiatrically Vulnerable

“[T]here are no permanent victories or defeats in politics.” 

— President Bill Clinton

As it is usually told, the fascinating story of how America came to embrace its now approximately half-century-long experiment in deinstitutionalizing psychiatrically vulnerable populations boils down to a set of easily identifiable heroes and villains. The latest chapter in this story is being written today, and what a plot twist it incorporates. But we are getting ahead of ourselves.

A detailed Capital Research Center paper from about 10 years ago sketches out noteworthy protagonists, plus some important dates and events. Deinstitutionalization as an activist cause didn’t really take off until two interest groups united behind it as a goal in the early 1970s. This pairing of like minds turned out to be more potent than perhaps anyone expected at the time it formed.

I mean here the alliance between activist attorneys affiliated with the American Civil Liberties Union (ACLU) and the deep pockets of the Edna McConnell Clark Foundation (EMCF). Starting in 1969, it was a unit of the national ACLU, the New York ACLU, that took the fight to end the old system of state mental hospitals into the courts and proposed alternative ways to care for the former residents of those institutions.

And EMCF’s role? EMCF would use its endowment, derived from the wealth generated through the Avon beauty-products business, to consistently fund years of litigation during the ’70s waged by ACLU activists to push the old model of care into history’s dustbin.

This was a powerful insurgent combination of money and legal/political smarts and, for a time, it was remarkably free—within the usual tolerant bounds of American pluralism around foundation/§501(c)(3) activities—to push for the reshaping of the old status quo. These are the heroic white hats of the conventional versions of the deinstitutionalization story.

Daring, Doubt, Disaster

And the black hats?

The black hats, in how the story is typically told, include everyone who dared to question whether deinstitutionalization would work. The bad guys also include then-California Gov. Ronald Reagan and several other Republican governors who, the white hats said, failed to fund, as demanded, a more-humane alternative to institutionalization.

This white-hat/black-hat approach to the story, as readers will have surmised, represents how the activists in this fight prefer to remember themselves, and how they see their opponents. Former ACLU executive Aryeh Neier’s memoir Taking Liberties is an illustrative example.

Over time, however, the human catastrophe that deinstitutionalization has wrought has become clear beyond any doubt. This disaster has taken the unmistakable shape of the hundreds of thousands of now-homeless individuals living in desperate circumstances across urban America.

The old white hats have had to face some tough questions. If the pre-deinstitutionalization system of state mental hospitals and other facilities represented a gross indignity against individual rights—and clearly there were cases of abuse and even brutality in the old system—the squalor that many of the urban homeless endure today can hardly be called an improvement in their condition.

Current Chapter

Now to more-recent developments in the deinstitutionalization story. The defenders of deinstitutionalization today face a more determined challenge than they have ever encountered since the end of the old system. In response to growing fears about a potential link between violent incidents and untreated mental illness, New York Mayor Eric Adams announced a plan about two years ago asserting that, per an official news release, “outreach workers, city-operated hospitals, and first responders have the legal authority to provide care to New Yorkers when severe mental illness prevents them from meeting their own basic human needs to the extent that they are a danger to themselves.”

That is to say, as Adams shared during a related address,

[W]e have issued a new directive to our Department of Health and Mental Hygiene mobile crisis teams, [fire crews and emergency medical service teams], and the NYPD. This directive lays out an expedited, step-by-step process for involuntarily transporting a person experiencing a mental health crisis to a hospital for evaluation. It explicitly states that it is appropriate to use this process when a person refuses voluntary assistance and it appears that they are suffering from mental illness and are a danger to themselves due to an inability to meet their basic needs.

Pluralism and (Lack of) Permanency

In its coverage of Adams’ actions on mental health, The New York Times has noted some close ties between elements of his administration and E. Fuller Torrey, an American psychiatrist and longtime policy gadfly who has highlighted the consequences of deinstitutionalization for decades—including through the Treatment Advocacy Center (TAC), a non-profit public education group that Fuller founded in 1998.

Torrey has repeatedly argued that, in cases of truly debilitating psychiatric illness such that individuals cannot properly care for themselves, some measure of “assisted outpatient treatment”—defined as court-supervised treatment of severe mental illness within the community—becomes necessary to stop vulnerable people from going into crisis.

With a relatively modest budget (and expenses of less than $3 million annually)—funded through individual donations and foundation support—TAC has had an outsized impact on the debate over whether deinstitutionalization has gone too far. As the Times points out, “[f]orty-seven states now have laws on assisted outpatient treatment, 30 of them developed with the involvement of TAC.”

It’s highly ironic that, some 50 years after the EMCF’s support of the ACLU helped end the old system of state mental hospitals and brought about deinstitutionalization, another philanthropically supported nonprofit is now working to undo much of that previous reform. It also says something important about the long-term stability of American political institutions and the basic enduring American commitment to pluralism.

In light of this ongoing story, we might amend and expand Bill Clinton’s line quoted above to give it a more optimistic tone, and add a nod to James Madison, who did so much to incorporate pluralism into the early American republic:

When a country has a truly rock-solid commitment to pluralism, including a shared and widespread respect for those basic norms, stated and unstated, upon which a stable national political culture depends—including among the specific factions, partisan or otherwise, trying to decisively influence the shape of policy touching key aspects of national life—then there can be no permanent victories or defeats in politics. [Emphasis supplied.]

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This article first appeared in the Giving Review on January 16, 2025.

Source: https://capitalresearch.org/article/philanthropy-nonprofits-and-deinstitutionalization-of-the-psychiatrically-vulnerable/