What characterises deinstitutionalisation?
> 1954 - 2012: steady, massive decline of hospital bed numbers
-> hospital closures
> 1954: 60 years of deinstitutionalisation began
- Renewed therapeutic optimism
- Newly-trained psychiatrists following WWII
> Peak bed numbers were reached at different times from the 1940s onwards
> 1950s - 1960s:
Rise of the Welfare State -> Social Security benefits
-> support people who couldn’t support themselves out of asylums
The District General Hospital movement “Psychiatry in White Coats”
-> new effective treatments
- Chlorpromazine: Psychosis
- Iproniazid and Imipramine: Depression
> 1970s: All advanced countries began the process of deinstitutionalisation (except Japan where bed number increased)
- England, Australia and New Zealand in the forefront
> 1978 “Italian Experience” : radical movement for closing all psychiatric institutions
What was the first sign anticipating the beginning of deinstitutionalisation, before 1954?
Mental Aftercare Association founded in 1879 by Colney Hatch Asylum.
What is deinstitutionalisation?
What are its 2 focuses?
A process of replacing long-stay psychiatric hospitals by less isolated community mental health services, for those diagnosed with mental disorders or developmental disability.
> Reducing the population size of mental institutions
- releasing patients, shorter stays, reducing admission/readmission rates
> Reforming mental hospitals’ institutional processes
- reduce/eliminate reinforcement of dependancy, hopelessness, learned helplessness… maladaptive behaviours
What are the steps of deinstitutionalisation?
- Running down the traditional mental hostpitals by improving throughput
- Developing community-based services
- Improving practice within the psychiatric hospitals
What is the perspective of E. Fuller Torrey in ‘Out of the shadows: Confronting America’s mental illness crisis’ (1997)?
What is his critic of deinstitutionalisation?
He writes from the perspective in the USA:
> A different social healthcare system where deinstitutionalisation started at the same time than in the UK, BUT proceeded much faster and further
> Deinstitutionalisation has resulted in people getting no care at all
- “Deinstitutionalisation further exacerbated the situation because, once the psychiatric beds had been closed, they were not available for people who later became mentally ill […]. Consequently, approximatively 2.2 million severely mentally ill people do not receive any psychiatric treatment
- “For a substantial minority, however, deinstitutionalisation has been a psychiatric Titanic. […] The “least restrictive setting” frequently turns out to be a cardboard box, a jail cell, or a terror-filled plagued by both real and imaginary enemies.”
What does Marshall (1998) call transinstitutionalisation?
What is his critic of deinstitutionalisation?
> “A process whereby individuals, supposedly deinstitutionalised as a result of community care policies, in practice end up in different institutions, rather than their own homes.”
-> an allied phenomena to deinstitutionalisation
> Deinstitutionalisation is a fiction
- what changed is the location of people’s institutionalisation
What is Andrew Scull’s critic of deinstitutionalisation (1977)?
‘Decarceration’ (1977, 1984):
> Motivation to close mental hospitals is to:
- save money
- shift costs
- encourage private sector (for profit providers)
“Evidence of benefits to [deinstitutionalised] psychiatric patients, especially those hospitalised over long periods, is not to be found anywhere in the psychiatric literature”
What evidence proved that Andrew Scull’s critic of deinstitutionalisation is wrong?
The Team for the Assessment of Psychiatric Services (TAPS) and other studies showed that:
- people improve in good quality community settings and deinstitutionalised hospital setting replacements
What is the optimistic view on deinstitutionalisation?
People are now living successful lives out of hospital following a diagnosis of severe mental illness and receiving appropriate treatment and community support.
What did we see in the US and in the UK during the deinstitutionalisation period?
- Mental hospitals got smaller
- Expansion of psychiatric units in general hospitals
- Development of free standing new small psychiatric hospitals
- Large mental hospitals closed
What can be criticised about the NHS bed data (KH03) on the deinstitutionalisation period?
> It ignores NHS-funded private sector beds
Steady reduction in bed numbers since 1954 in the face of a rising population
(purchased private sector beds are now included in the total bed numbers)
What do international trends in inpatient provision show between the 1970s and now?
All European countries have now less beds than they had in the 1970s.
What does the Project Atlas by WHO (2005) show about the European data on trends in the numbers of psychiatric beds in Western Europe?
> The UK deinstitutionalised more aggressively than most other high-income countries
- six-fold reduction (6 times less) from 1954 to 2004
- nine-fold reduction (9 times less) from 1954 to 2015
> Mean bed numbers in high-income countries in 2004: 75 / 100,000
UK in 2004: 58 / 100,000
- now 42 / 100,000
-> low in international comparison
What are the drivers of deinstitutionalisation?
- Psychotropic medication revolution
- Changes in professional attitudes post-WWII
- The “open-door” movement in mental hospitals
- The introduction of occupational therapy and work rehabilitation in the mental hospitals in the 1950s
- The rise of the “Welfare State” and change of access to welfare benefits
- The attractive concept of “community care”
- Evolution of mental health law
- Ideas about institutions
- Cost
What does Russel Barton (1959) call “Institutional neurosis”?
A ‘syndrome’ of apathy, lack of initiative, loss of interest and submissiveness.
What does Erving Goffman present in ‘Asylums’ (1961)?
A sociological critique of the asylum and other “total institutions”.
What does Wing and Brown present in ‘Institutionalism And Schizophrenia’ (1970)?
Empirical study:
> The effect of institutional practices on psychiatric disability
> “Negative symptoms” of schizophrenia
- reactive to the social environment in the 3 hospitals they studied
What does the American neurologist S Weir Mitchell (1894) think of asylums?
“Upon my word, I think asylum life is deadly to the insane”.
Is there an example of politics as a driver for deinstitutionalisation?
Enoch Powell (then Minister of Health),
Speech to the Conservative Part Conference (1961):
“Do not for a moment underestimate their powers of resistance to our assault” (his decision to close mental hospitals).
How was the hospital closure process in the USA?
Early and rapid deinstitutionalisation aided by financial and legal drivers.
- e.g. mass action suits instructed mental hospitals to discharge patients en masse
What was one of the first hospitals to close in England?
What was the state of hospital closure by 2000?
> Banstead Hospital closure in 1986
> By 2000, the majority of mental hospitals had closed
What were the common factors in hospital scandals, described in J.P. Martin’s ‘Hospitals in trouble’ (1984)?
Hospital scandals concerning the mentally ill, the elderly and people with learning disabilities: > Poor top management > Poor nursing leadership > Poor medical leadership > Lack of multidisciplinary working > Distorted unit culture > Lack of clarity over task of unit (relevant to long-stay institutions) > Isolation
What were the financial issues of deinstitutionalisation?
- Significant capital value to be released on closure
- Changes in Social Security-funded community care services -> cost-shifting from one budget to another
- Fixed costs irrespective of bed numbers
What were the outcomes of deinstitutionalisation?
> The English hospital closure programme
- began in 1986
- use of some sites for general hospitals and part-use of sites for inpatient units
- development of small “secure” hospitals within the NHS and the private sector
> 116 of the 130 traditional Mental Hospitals in England and Wales had closed by 2001
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Conceptualisations of mental disorder22
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Mental Illness and its critics17
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Diagnosis in psychiatry35
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A brief history of madness26
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Deinstitutionalisation27
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Community psychiatry13
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Stigma and mental health26
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'Nothing about me without me': The growth of the expert by experience30
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Evaluating service user involvement12
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Coercion in mental health care22
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The epidemiology of mental disorder21
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The burden of mental ill-health for the individual17
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The societal burden of mental ill-health16
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Psychological approaches28
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Psychological approaches II: beyond the individual couple, family, and group work31
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Community care in practice23
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Building the brain16
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Dysfunction of pathways30
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Medications and their effects17
