We turn now from our discussion of the underpinnings of our understandings of madness and misery and reorient ourselves more with the last 20 years and current state of affairs for ‘people with serious mental illness’. Of the many institutional changes that can be used to enhance our understanding of recent years, there is the continuing centrality of psychotropic medication, with a decreasing reliance on long-term hospital institutionalisation. However, many have argued that ‘softer’ forms of institutional arrangements such as group homes and residential facilities (Bellack and Mueser, 1986) and even harsher ones in the forms of prisons and jails (Pepper and Massaro, 1992) constitute a form of trans-institutionalisation. There are dramatic shifts and cuts in funding for services (Frank and Glied, 2006; Grob and Goldman, 2006; McCrone et al., 2008), which have left the system even more resource-hungry and eager to accept cost-effective alternatives.
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