Published on November 20, 2008
Contemporary Adult Mental Health and Social Policy: Contemporary Adult Mental Health and Social Policy Deinstitutionalisation: From Back ward to Back Bedroom De-institutionalisation Defined: De-institutionalisation Defined De-institutionalisation refers to the shift of patients from psychiatric hospital to community based care Bachrach (1976) 'contraction of institutional settings with a corresponding increase in community based settings'. The policy of de-institutionalisation calls for the provision of treatment and supportive care for medically and socially dependent individuals in the community rather than an institutional setting. Rather than hospitals attempting to meet health and social needs of patients, this task is now undertaken by a range of primary and secondary health and social care providers. Context of De-institutionalisation: Context of De-institutionalisation Introduction of new anti-psychotics Decline of the asylum Scandals about standards of care in psychiatric institutions Community care appealed to politicians and administrators concerned with current and projected costs associated with psychiatric hospital care. Transfer of assets from public to private Antipsychiatry: an intellectual background: Antipsychiatry: an intellectual background Erving Goffman: Asylums Michel Foucault: Madness & Civilization Thomas Szasz: The Myth of Mental Illness RD Laing: The Divided Self Mental Hospital Patients Ireland 1914-1962: Mental Hospital Patients Ireland 1914-1962 Crisis? What crisis?: ‘I am compelled to say at this stage that the overcrowded conditions for our patients in St Brendan’s are contrary to every modern idea of human society.’ Medical Superintendent, St Brendan’s Hospital, (1957) ‘The uphill struggle to modernise these hospitals, to relieve overcrowding and to achieve a satisfactory standard continues, but there is still a long way to go before our services can be regarded as adequate.’ Inspector of Mental Hospitals, (1960) Crisis? What crisis? Commission of Inquiry on Mental Illness Report 1966: Commission of Inquiry on Mental Illness Report 1966 Greater emphasis on community based services Integration of psychiatric services into general hospitals Development of outpatient services Rehabilitation of long-stay patients Establishment of specialist services (alcohol, drugs, children etc) Improvements in staff training and education Easing of admissions procedures In-patient population 1963-2004: In-patient population 1963-2004 Community Psychiatry: Community Psychiatry The philosophy of the community psychiatry movement revolves around the concept of delivery of psychiatric services according to the needs of the community—that is, when where and how required. Institutional Consequences: Institutional Consequences Instead of services and resources being consolidated in one space within a unified group of buildings, they are now provided in a more indeterminate and fragmented spatial framework where networks of community psychiatrists, Doctors, psychologists and social workers work on a one-to-one basis with patients dispersed over a wide area. The asylum had been the forum in which psychiatry has asserted its professional dominance: with the decline of the asylum the professional dominance of psychiatrists has diminished. Proliferation of other mental health professionals Consequences for the mentally ill: Consequences for the mentally ill In practice the long-stay inmate population have been subject less to a process of deinstitutionalisation, than to one of transinstitutionalisation, often ending up in boarding-houses, nursing homes, homes for the elderly, or even prisons. People who in earlier times would have almost certainly been labelled mentally ill and sent to mental hospitals are increasingly being imprisoned, confined without treatment. People with SMI may lack insight into their condition and may be reluctant to seek help or actively avoid contact with services leading to enforced medication in the home. Concerns about untoward incidents involving people with SMI- repeated official enquiries have linked incidents to failure to co-ordinate patient care. Consequences for the mentally ill: Consequences for the mentally ill Higher levels of morbidity (Howells 1997), Lower levels of health promotion (Kerr, et al 1996), Lower rates of consultation compounded by problems of understanding and communication. (Howells 1986; Cole 1986; Wilson & Haire 1990) Issues of social inclusion: Issues of social inclusion Mentally ill people suffer problems connected with social inclusion Even mild mental illness can lead to problems of employment, poverty, marginalisation and discrimination It is only recently that community care policies have developed to address these wider issues Community Care: How not to do it: Community Care: How not to do it In the British context, by 1957 community care, as initially envisaged, aimed to develop services such as halfway houses and training centres outside the mental hospital these services were still to be publicly funded and it was the cost of alternative provisions that hampered the implementation of community care in the 1960s and 1970s. By the 1980s, psychiatric populations began a steady and then increasingly rapid decline as a result of policies of deinstitutionalisation, culminating in the mid- to late-1990s. Community care covered anything that ‘did not involve residence in a large institution’, According to Busfield ‘the term does not require that there be any professional service at all, and informal care by family and friends, let alone homelessness and neglect’ could ‘all fall within the framework of community care’. Deinstitutionalisation Studies 1: Deinstitutionalisation Studies 1 As part of the Berlin Deinstitutionalisation Study, quality of life was assessed in 142 patients at two points of time. Discharged patients were reassessed one year after discharge. Patients who stayed in hospital were reinterviewed 1 1/2-2 years after the initial assessment. Discharged patients had more leisure activities, more often a "good friend", and more frequent social contacts. They were less often victim of a crime within the last year. In a cross-sectional comparison, they were significantly more satisfied with their life than patients who were still in hospital. Discharged patients became significantly more satisfied with their life in general, with leisure activities, with accommodation, and with mental health between initial assessment and follow-up. Deinstitutionalisation Studies 2: Deinstitutionalisation Studies 2 The closure of a long-stay psychiatric hospital in Sydney caused the transfer of an initial 40 very long-term patients to four community residences, each with 10 beds, for a continuing process of deinstitutionalisation. Community psychiatric service support and 24-h supervision were provided. 35 residents in total who remained in the community for 2 years, demonstrated a significant improvement in psychotic symptoms, without significant change in the level of neuroleptic medication. 2 years of community living resulted in a significant increase in the residents' life satisfaction. There were no statistically significant changes in residents' living skills, depressive symptoms or social behaviour problems over the 2 years, indicative of the need for supervision and community service support following deinstitutionalisation. Over the 2-year period, some 37% of the residents required temporary readmission. Deinstitutionalisation Studies 3: Deinstitutionalisation Studies 3 Evaluation of costs and outcomes for 128 people who moved to community services between 1986 and 1987. 128 users had been living in the same hospital for an average of 12 years evaluated 12 years later Study found significant reductions in users’ mobility, their ability to wash, bathe and dress, and in their appearance. Clarity of speech was thought to have deteriorated, but conversation and social interaction had improved. Ratings of co-operative behaviour had decreased and argumentative behaviour increased. The majority of residents were functioning quite well and had relatively few symptoms and behavioural problems but around a quarter of users were significantly impaired, and 10–15 per cent presented quite serious problems. There was some evidence of an overall increase in symptoms and behaviour problems since leaving hospital. There were marginally significant increases in the reported incidence of odd gestures and mannerisms, obsessiveness, depression and suicidal preoccupation. Further Reading: Further Reading Barham p(1997) Closing the Asylum: The Mental Patient in Modern Society, 2nd ed Harmondsworth: Penguin. Cambridge P et al (2003) Twelve years on: outcomes and costs of deinstitutionalisation for people with mental health problems Mental Health Research Review 9, 10-12 Hobbs et al (2000) Deinstitutionalisation for long-term mental illness : a 2-year clinical evaluation Australian and New Zealand Jnl of psychiatry 34 (3) 476-483 Hoffmann K et al (2000) Quality of life in the course of deinstitutionalisation Psychiatr Prax. 27 (4) 183-8 Ramon S (1996) Mental Health in Europe Ends, Beginnings and Rediscoveries London: Macmillan Scull A Asylums: Utopias and Realities’, D Tomlinson & J Carrier (eds),199 Asylum in the Community, London and New York: Routledge
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