Ironies of inclusion: social class and deinstitutionalization

This paper discusses changes in the social organization of mental institutionalization as they relate to developments in the wider social and economic environment. Despite dramatic changes in the system of inpatient psychiatric care during the last three decades, the historic division of labor between the private and the public system (with the latter treating the poor, the unemployed, and the nonwhite) has not ceased to exist. At the same time, under the influence of the postwar trend towards greater political integration of disadvantaged and marginal groups into society's central value systems, treatment of the mentally ill has become less segregated and more voluntary. An important implication of these two interacting trends--the changed legal position of the patient vis-à-vis the provider and the deteriorating economic position of the user of public psychiatric facilities--has been the exceeding irrelevance of one of the basic tenets of psychiatric care: that clinical treatment precedes social functioning. With two vignettes of chronic patients the article illustrates how symptoms and survival are fused in the contemporary, inclusionary system of care.