Deinstitutionalisation
The modern deinstitutionalisation movement was made possible by the discovery of psychiatric drugs in the mid-20th century, which could manage psychotic episodes and reduced the need for patients to be confined and restrained.
In contrast to the prison-like asylums of old, these were designed to be comfortable places where patients could live and be treated, in keeping with the movement towards "moral treatment".
One stated aim was to improve the health of the nation by ‘breeding out defects’, isolating people with disabilities and ensuring they could not procreate.
Charles Darwin's son lobbied the British government to arrest people deemed as ‘unfit’, then segregate them in colonies or sterilise them.
[9] The medical and administrative teams who developed the first mass extermination programme were transferred – together with their killing technology – to set up and manage the death camps of Treblinka and Sobibor during the Holocaust.
[1] 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.
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.
[34] and the psychiatric field continued to research whether "hospitals" (e.g., forced involuntary care in a state institution; voluntary, private admissions) or community living was better.
[36][37][38][39] These women follow university education on social control and the myths of deinstitutionalization, including common forms of transinstitutionalization such as transfers to prison systems in the 21st century, "budget realignments", and the new subterfuge of community data reporting.
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).
Some researchers argue that this created economic incentives to increase the frequency of psychiatric diagnosis (and related diagnoses, such as ADHD in children) that did not happen in the era of costly hospitalized psychiatry.
It has been argued that in United States, loss of low-income housing and disability benefits are the core causes of homelessness historically and placing the blame on deinstitutionalization is an oversimplification which does not take into account the other policy changes which occurred during the same time.
[5] Julie Racino argues that having a closed social circle like this can limit opportunities for mentally ill people to integrate with the wider society, such as personal assistance services.
[54] Torrey has opposed deinstitutionalisation in principle, arguing that people with mental illness will be resistant to medical help due to the nature of their conditions.
[55] He believes that reducing psychiatrists' powers to use involuntary commitment led to many patients losing out on treatment,[56] and that many who would have previously lived in institutions are now homeless or in prison.
[41] Another form of critique argues that while deinstitutionalization was a move in the right direction and had laudable goals, many shortcomings in the execution stage have made it unsuccessful thus far.
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.
Participants were offered counselling to help them deal with their experiences, along with advice on their rights, including access to records and legal redress.
The Mental Treatment Act 1945 caused some modernisation but by 1958 the Republic of Ireland still had the highest psychiatric hospitalisation rate in the world.
The 1963 Irish Psychiatric Hospital Census noted the extremely high hospitalisation rate of unmarried people; six times the equivalent in England and Wales.
After working with Edelweiss Cotti in 1968 at the Centro di Relazioni Umane in Cividale del Friuli – an open ward created as an alternative to the psychiatric hospital – 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.
[72] The reform was focused on the gradual dismantlement of psychiatric hospitals, which required an effective community mental health service.
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.
[79] 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.
[79] 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.
[79] His administration sponsored the successful passage of the Community Mental Health Act, one of the most important laws that led to deinstitutionalization.
The Rosenhan's experiment in 1973 caused several psychiatric hospitals to fail to notice fake patients who showed no symptoms once they were institutionalized.
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.
[5] In Brazil, there are 6,003 psychiatrists, 18,763 psychologists, 1,985 social workers, 3,119 nurses and 3,589 occupational therapists working for the Unified Health System (SUS).
The number of psychiatric nurses is insufficient in all geographical areas, and psychologists outnumber other mental health professionals in all regions of the country.
