Deinstitutionalisation

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Deinstitutionalisation (from de-institution-alisation) is the process of replacing long-stay mental institutions with less isolated community mental health services for those diagnosed with mental disorder or developmental disability.

Origins

The 19th century saw a large expansion in the number and size of asylums in Western industralized countries. Although initially based on principles of moral treatment, they became overstretched, untherapeutic, isolated in location and neglected in practice.^[1]

20th Century

By the beginning of the 20th century, ever-increasing admissions had resulted in serious overcrowding. Funding was often cut, especially during periods of economic decline, and during wartime in particular many patients starved to death. Asylums became notorious for poor living conditions, lack of hygiene, overcrowding, and ill-treatment and abuse of patients.^[2]

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 deinstitutionalization came to the fore in various countries in the 1950s and 1960s. The prevailing public arguments, time of onset, and pace of reforms varied by country.^[2]Class action lawsuits in the United States, and the scrutiny of institutions through disability activism and antipsychiatry, helped expose the poor conditions and treatment. Sociologists and others argued that such institutions maintained or created dependency, passivity, exclusion and disability, causing people to be institutionalized. There was an argument that community services would be cheaper. It was suggested that new psychiatric medications made it more feasible to release people into the community.^[3]

There were differing views on deinstitutionalization, however, in groups such as mental health professionals, public officials, families, advocacy groups, public citizens, and unions.^[4]

Consequences

Community services that developed included supported housing with full or partial supervision, and specialized teams (such as Assertive community treatment and early intervention teams) in the community. Costs have been reported to be generally the same as for inpatient hospitalization, or lower in some cases (depending how well or poorly funded community alternative are).^[2] Some regions introduced laws enabling the forced medication in the community of those with psychiatric diagnoses.

Although there is widespread consensus that deinstitutionalization has been successful in preventing unnecessary long-term hospitalization, its implementation has also been criticized. Existing patients were often discharged without sufficient preparation or support. New community services were often uncoordinated and unable to meet complex needs. Expectations that community care would lead to fuller social integration were not achieved; many remain without work, have limited social contacts and often live in sheltered environments. Services in the community sometimes provide a new ghetto, where service users meet each other but have little contact with the rest of the community. It has been said that instead of "community psychiatry", reforms established a "psychiatric community".^[2]

In 2000, results from a prospective two-year study of patients discharged from a mental hospital showed that stigma was a powerful and persistent force in their lives, and that experiences of social rejection were a persistent source of social stress. Efforts to cope with labels, such as not telling anyone, educating people about mental distress/disorder, withdrawing from stigmatizing situations, could result in further social isolation and reinforce negative self-concepts. Sometimes an identity as a low self-esteem minority in society would be accepted. The stigma was associated with diminished motivation and ability to "make it in mainstream society" and with "a state of social and psychological vulnerability to prolonged & recurrent problems". There was an up and down pattern in self-esteem, however, and it was suggested that, rather than simply gradual erosion of self-worth and increasing self-deprecating tendencies, people were sometimes managing, but struggling, to maintain consistent feelings of self-worth. Ultimately, "a cadre of patients had developed an entrenched, negative view of themselves, and their experiences of rejection appear to be a key element in the construction of these self-related feelings" and "hostile neighbourhoods may not only affect their self-concept but may also ultimately impact the patient's mental health status and how successful they are".^[5]

Following deinstitutionalization, a greater proportion of people with mental disorders became homeless or went to prison. Widespread homelessness occurred in some states in the USA and some other countries.^[2]

Moves to community living and services 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 in a year, a proportion eleven times higher than the inner-city average. The proportion is many times greater in every category of crime, including rape/sexual assault, other violent assaults, and personal and property theft. The rates are similar in those with developmental disabilities.^[6][7] Despite perceptions by the public and media that people with mental disorders released in to the community are more likely to be dangerous and violent, a large study indicated that they were no more likely to commit violence than those in the neighbourhoods (usually economically deprived and high in substance abuse and crime) to which they typically moved.^[8] Findings on violence committed by those with mental disorders in the community have been inconsistent and related to numerous factors; a higher rate of the most serious offences such as homicide has sometimes been found but, despite high-profile homicide cases, the evidence suggests this has not increased over the period of deinstitutionalization.^[9][10][11] Aggression and violence that does occur, in either direction, is usually within families rather than between strangers^[12]

Deinstitutionalisation around the world

Asia

In Japan, the number of hospital beds has risen steadily over the last few decades.^[2]

In Hong Kong, a pseudo-community care model provides services such as half-way houses, long-stay care homes and a day-care centre, but all away from the community.^[2]

Australia

New Zealand established a reconciliation initative in 2005 in the context of ongoing compensation payouts to ex-patients of state-run mental institutions in the 1970s to 1990s. The forum heard of poor reasons for admissions; unsanitary and overcrowded conditions; lack of communication to patients and family members; physical violence and sexual misconduct and abuse; inadequate complaints mechanisms; pressures and difficulties for staff, within an authoritarian psychiatric hierarchy based on containment; fear and humiliation in the misuse of seclusion; over-use and abuse of ECT, psychiatric medication and other treatments/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 counseling to help them deal with their experiences, and advice on their rights, including access to records and legal redress.^[13]

Africa

Uganda has one psychiatric hospital.^[2]

Europe

Countries where deinstitutionalization has happened may be experiencing a process of "re-institutionalization" or relocation to different institutions, as evidenced by increases in the number of supported housing facilities, forensic psychiatric beds and rising numbers in the prison population.^[14]

Some developing European countries still rely on asylums.

North America

United States

In 1970 there were 413,066 beds in state and county mental hospitals in the United States. By 1988, this number had decreased to 119,033. By 1998, it was 63,526 beds.^[15]

A significant catalyst of deinstitutionalization was the Community Mental Health Act of 1963. It has been used by some governments and their agencies to attempt to save money by closing down, scaling back or merging psychiatric inpatient units. In 1999, the Supreme Court of the United States ruled in L.C. & E.W. v. Olmstead that states are required to provide community-based services for people with mental disabilities if treatment professionals determine that it is appropriate and the affected individuals do not object to such placement.

A number of factors led to an increase in homelessness, including macroeconomic shifts, but observers also saw a change related to deinstitutionalization.^[16][17][18] Studies from the late 1980s indicated that one-third to one-half of homeless people had severe psychiatric disorders, often co-occuring with substance abuse.^[15][19]

A process of indirect cost-shifting may have led to a form of "re-institutionalization" through the increased use of jail detention for those with mental disorders deemed unmanageable and noncompliant.^[20]

South America

In several South American countries, the total number of beds in asylum-type institutions has decreased, replaced by psychiatric inpatient units in general hospitals and other local settings.^[2]

References

Source: Wikipedia

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