Deinstitutionalisation

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

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 or in halfway houses, clinics and 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.[1]

The modern deinstitutionalisation movement was initiated by three factors:

  • A socio-political movement for community mental health services and open hospitals;
  • The advent of psychiatric drugs able to manage psychotic episodes;
  • Financial imperatives (in the US specifically, to shift costs from state to federal budgets)[2]

The movement to reduce institutionalisation was met with wide acceptance in Western countries, though its effects have been the subject of many debates. Some experts, such as E. Fuller Torrey, have argued that deinstitutionalisation was a mistake,[3] while others, such as Thomas Szasz, argue it did not provide enough freedom for patients.[4] Others have argued that it was an improvement on the system that existed before. Psychiatrist Leon Eisenberg has argued that it has generally been beneficial for psychiatric patients, while noting that some were left homeless or without care.[2]

Origins[edit]

19th century[edit]

The 19th century saw a large expansion in the number and size of asylums in Western industrialised countries. Although initially based on principles of moral treatment, they became overstretched, non-therapeutic, isolated in location, and neglectful of patients.[5]

20th century[edit]

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.[6]

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. 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.

The prevailing public arguments, time of onset, and pace of reforms varied by country.[6] In the United States, class action lawsuits and the scrutiny of institutions through disability activism and antipsychiatry helped expose poor conditions and treatment. Sociologists and others argued that such institutions maintained or created dependency, passivity, exclusion, and disability, which caused people to remain institutionalised. Rosenhan's experiment in 1973 "accelerated the movement to reform mental institutions and to deinstitutionalize as many mental patients as possible."[7]

A prevailing argument claimed that community services would be cheaper and that new psychiatric medications made it more feasible to release people into the community.[8] Mental health professionals, public officials, families, advocacy groups, public citizens, and unions held differing views on deinstitutionalisation.[9]

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.[10][11][12] The book is one of the first sociological examinations of the social situation of mental patients, the hospital.[13] 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.[14]

The American Association for the Abolition of Involuntary Mental Hospitalisation (AAAIMH) was an organisation founded in 1970 by Thomas Szasz, George Alexander, and Erving Goffman for the purpose of abolishing involuntary psychiatric intervention, particularly involuntary commitment, against individuals.[15] The founding of the AAAIMH was announced by Szasz in 1971 in the American Journal of Public Health[16] and American Journal of Psychiatry.[17] The association provided legal help to psychiatric patients and published a journal, The Abolitionist.[18] The organization was dissolved in 1980.[18][19]

American psychiatrist Loren Mosher noticed that the psychiatric institution itself gave him master classes in the art of the "total institution": labeling, unnecessary dependency, the induction and perpetuation of powerlessness, the degradation ceremony, authoritarianism, and the primacy of institutional needs over those of the persons it was ostensibly there to serve-the patients.[20]

In New York ARC v. Rockefeller, parents of 5,000 residents at the Willowbrook State School in Staten Island, New York, filed suit over the inhumane living conditions at that institution, where residents were abused and neglected. A 1972 television broadcast from the Willowbrook State School, titled "Willowbrook: The Last Great Disgrace," outraged the general public. However, it took 3 years from the time the lawsuit documents were filed before the consent judgement was signed. In 1975, the consent judgement was signed, and it committed New York state to improve community placement for the now designated "Willowbrook Class." The Willowbrook State School was closed in 1987, and all but about 150 of the former Willowbrook residents were moved to group homes by 1992.[21][22][23][24][25]

In 1973, a federal district court ruled in Souder v. Brennan that patients in mental health institutions must be considered employees and paid the minimum wage required by the Fair Labor Standards Act of 1938 whenever they performed any activity that conferred an economic benefit on an institution. Following this ruling, institutional peonage was outlawed, as evidenced in Pennsylvania's Institutional Peonage Abolishment Act of 1973.

Consequences[edit]

There is an increased incarceration for the mental health population due to mental health treatment facilities being closed as a result of the lack of government funding. The solution is to put money back into mental health treatment facilities to decrease the mental health population in jail. Better Mental health services would combat not only mental illness, but homelessness as well. In a survey by the United States Conference of Mayors (2008), 20 percent of cities listed better coordination with mental health service providers as one of the top three items needed to combat homelessness. Incarceration and homelessness are mutual risk factors for each other. Researchers generally estimate that 25-50 percent of the homeless population has a history of incarceration. According to the Substance Abuse and Mental Health Services Administration, 20 to 25 percent of the homeless population in the United States suffers from some sort of severe mental illness (SAMSHA 2018). About a fifth of America’s 1.7 million homeless population suffer from untreated schizophrenia or manic-depressive illness. According to the National Coalition for the Homeless, when you focus in on single adult homeless males, about 16% of them suffer from some form of severe and persistent mental illness. There is general agreement among researchers that the number of mentally ill individuals in jail is substantial, and that many of these individuals are arrested for minor crimes, particularly disorderly conduct or trespassing. There is evidence that a large percentage of jailed individuals may also have been homeless at the time of arrest. Nearly 21 percent were classified as homeless when they were arrested and 40 percent said they had been homeless at some time during the past few years. The researchers concluded that homelessness significantly increases the risk of indictment for violent criminal offenses among mentally disordered offenders (National Coalition for the Homeless 2009).

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).[6] 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".[6] Sometimes these groups have similar criticisms. Both argue that many patients became homeless or in prison.[26][6]

New community services are often uncoordinated and unable to meet complex needs. Services in the community sometimes isolate the mentally ill within a new ghetto, where service users meet each other but have little contact with the rest of the public community. Fakhoury and Priebe said that instead of "community psychiatry", reforms established a "psychiatric community".[6]

Families can often play a crucial role in the care of those who would typically be placed in long-term treatment centres. However, many mentally ill people are resistant to such help due to the nature of their conditions. The majority of those who would be under continuous care in long-stay psychiatric hospitals are paranoid and delusional to the point that they refuse help, believing they do not need it, which makes it difficult to treat them.[27]

Violence[edit]

Victimisation[edit]

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.[28][29]

Misconceptions[edit]

Despite perceptions by the public and media that people with mental disorders released into the community are more likely to be dangerous and violent, a large study indicated that those 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.[30]

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.[31][32][33] The aggression and violence that does occur, in either direction, is usually within family settings rather than between strangers.[34]

Worldwide[edit]

Asia[edit]

Hong Kong[edit]

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[edit]

In Japan, the number of hospital beds has risen steadily over the last few decades.[6]

Africa[edit]

Uganda has one psychiatric hospital.[6]

Australia and Oceania[edit]

New Zealand[edit]

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.[35]

Europe[edit]

In some countries[specify] 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.[36]

Some developing European countries[specify] still rely on asylums.

Italy[edit]

Italy was the first country to begin the deinstitutionalisation of mental health care and to develop a community-based psychiatric system.[37] The Italian system served as a model of effective service and paved the way for deinstitutionalisation of mental patients.[37] Since the late 1960s, the Italian physician Giorgio Antonucci questioned the basis itself of psychiatry; 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.[38] In 1978, the Basaglia Law had started Italian psychiatric reform that resulted in the end of the Italian state mental hospital system in 1998.[39]

The reform was focused on the gradual dismantlement of psychiatric hospitals, which required an effective community mental health service.[14]:665 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.[14]:664

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.[38]

United Kingdom[edit]

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.[40] The government of Harold Macmillan sponsored the Mental Health Act 1959,[41] 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.[42] The campaigns of Barbara Robb and several scandals involving mistreatment at asylums (notably Ely Hospital) furthered the campaign.[43] The Ely Hospital scandal led to an inquiry led by Brian Abel-Smith and a 1971 white paper that recommended further reform.[44]

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.[45]

North America[edit]

United States[edit]

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

The United States has experienced two main waves of deinstitutionalisation. The first wave began in the 1950s and targeted people with mental illness.[1] The second wave began roughly 15 years later and focused on individuals who had been diagnosed with a developmental disability.[1] 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.[46]

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.[1][2] The federal government offered financial incentives to the states to achieve this goal.[1][2] 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.[1] 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.[1]

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.[1] 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,[1] 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).[1]

The 1970s saw some key court rulings that increased the rights of patients, due to lawsuits from these advocacy groups. In 1973, a federal district court ruled in Souder v. Brennan that patients in mental health institutions must be considered employees and paid the minimum wage required by the Fair Labor Standards Act of 1938 whenever they performed any activity that conferred an economic benefit on an institution. Following this ruling, institutional peonage was outlawed. In 1975, the U.S. Supreme Court restricted the rights of states to incarcerate someone who was not violent. This was followed up with a 1978 ruling 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 of Rogers v. Okin,[1] 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 include 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.[7] 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[edit]

In several South American countries,[specify], 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.[6]

See also[edit]

General

References[edit]

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Bibliography[edit]

Further reading[edit]