“the Freedom Factor”: Two-Year Outcomes for People Discharged Following a Psychiatric Hospital Closing

Deinstitutionalization has been among the most important changes in mental health services in the past half century.  Many public systems are now moving towards designs in which there will be no long-stay state supported psychiatric hospital.  Although concerns have been raised about homelessness and incarceration, we still know relatively little about how people fare when they are discharged to community settings, and how they experience this life transition. 

This mixed-methods study reports on the two-year outcomes of a random sample (N=65) of people discharged when a state psychiatric hospital was closed.  Interviewers visited participants every three months for two years.  Standardized assessments, conducted every six months, included psychiatric symptomatology (BPRS), quality of life (WHOQOL Bref), social adjustment (SAS-II, Social and Leisure Subscale) and progress towards recovery (RAS). Qualitative observation included observation, and conversations with participants and providers every three months, and formal interviews regarding the discharge experience. 

Latent growth curve analysis was used to assess change over time.  Average BPRS score decreased from 39.5 in the hospital to 28.5 two years post-discharge t (155) = 5.79, p < .001.  60% of study participants met a recently published criterion for remission of symptoms of schizophrenia at the end of the two year study period.  Social functioning according to the SAS-II Social and Leisure subscale also improved, t (144) = 2.92, p < .005, and the percentage of participants who reported regularly seeing friends increased from 26% to 41% .  Quality of life and progress towards recovery did not change over the course of the study, but compared favorably to rates reported in epidemiological studies of community-dwelling people with psychiatric disabilities. 

Interviews clearly showed that participants preferred community residences to the hospital.  As one participant said, “It’s the freedom factor”.  Participants preferred living in smaller settings in which they had more say over when and where to go out, room décor, choice of music and television programming, and other choices of activities.  Mental health providers remained the most important source of social activity and support for most people.  On the whole, engagement with the community integration remained limited, and is an area for future work for mental health services providers.  A subset of people developed independent relationships, found work, and participated in volunteer activities.  In contrast, another small subset of people, many of whom explicitly valued the choice and freedom of the community setting, initiated or renewed risky behaviors, sometimes involving illegal substances, and some of these people were incarcerated for periods of time. 

This study adds to a growing body of evidence that people with psychiatric disabilities can be well served without resorting to long stay largely custodial hospital residences.  Quality of life, living circumstances, and mental health status were stable or improved during the two years following the hospital closing.  Participants were largely positive about the discharge experience and their new residences, compared to the hospital.  As said by one participant “The best experience has been knowing that I can make it in the real world”.