Deinstitutionalisation
Deinstitutionalisation 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 1950s and 1960s, it led to the closure of many psychiatric hospitals, as patients were increasingly cared for at home, in halfway houses, group homes, and clinics, in regular hospitals, or not at all.
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 feelings of dependency, hopelessness and other behaviours that make it hard for patients to adjust to a life outside of care.
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. Another major impetus was a series of socio-political movements that campaigned for patient freedom. Lastly, there were financial imperatives, with many governments also viewing it as a way to save costs.
The movement to reduce institutionalisation was met with wide acceptance in Western countries, though its effects have been the subject of many debates. Critics of the policy include defenders of the previous policies as well as those who believe the reforms did not go far enough to provide freedom to patients.
History
19th century
The 19th century saw a large expansion in the number and size of asylums in Western industrialised countries. 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". In spite of these ideals, they became overstretched, non-therapeutic, isolated in location, and neglectful of patients.20th century
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. 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.Eugenics and Aktion T4
The eugenics movement started in the late 19th century, but reached the height of its influence between the two world wars. 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.At the same time, in Germany medics and lawyers joined forces to argue for the extermination of people with disabilities. The 1920 essay, "Permitting the Destruction of Life Unworthy of Life" is seen by many as a blueprint for the Nazis' future crimes against humanity.
In 1939, the Nazi regime began 'Aktion T4'. Through this programme, psychiatric institutions for children and adults with disabilities were transformed into killing centres. The government compelled midwives to report all babies born with disabilities, then coerced parents to place their children in institutions. Visits were discouraged or forbidden. Then medical personnel transformed a programme of institutionalisation into extermination.
More than 5,000 children were killed in the network of institutions for children with disabilities, followed by more than 200,000 disabled adults. 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.
The Nazi crimes against people with mental illness and disabilities in institutions was one of the catalysts for moving away from an institutionalised approach to mental health and disability in the second half of the 20th century.
Origins of the modern movement
The advent of chlorpromazine and other antipsychotic drugs in the 1950s and 1960s played an important role in permitting deinstitutionalisation, but it was not until social movements campaigned for reform in the 1960s that the movement gained momentum.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. The book is one of the first sociological examinations of the social situation of mental patients, the hospital. Based on his participant observation field work, the book details Goffman's theory of the "total institution" and the process by which it takes efforts to maintain predictable and regular behaviour 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 to the same process of institutionalism. Other critics went further and campaigned against all involuntary psychiatric treatment. In 1970, Goffman worked with Thomas Szasz and George Alexander to found the American Association for the Abolition of Involuntary Mental Hospitalisation, who proposed abolishing all involuntary psychiatric intervention, particularly involuntary commitment, against individuals. The association provided legal help to psychiatric patients and published a journal, The Abolitionist, until it was dissolved in 1980.
Reform
The prevailing public arguments, time of onset, and pace of reforms varied by country. Leon Eisenberg lists three key factors that led to deinstitutionalisation gaining support. The first factor was a series of socio-political campaigns for the better treatment of patients. Some of these were spurred on by institutional abuse scandals in the 1960s and 1970s, such as Willowbrook State School in the United States and Ely Hospital in the United Kingdom. The second factor was new psychiatric medications made it more feasible to release people into the community and the third factor was financial imperatives. There was an argument that community services would be cheaper. Mental health professionals, public officials, families, advocacy groups, public citizens, and unions held differing views on deinstitutionalisation.However, the 20th century marked the development of the first community services designed specifically to divert deinstitutionalisation and to develop the first conversions from institutional, governmental systems to community majority systems. These services are so common throughout the world that they are often "delinked" from the term deinstitutionalisation. Common historical figures in deinstitutionalisation in the US include Geraldo Rivera, Robert Williams, Burton Blatt, Wolf Wolfensberger, Gunnar Dybwad, Michael Kennedy, Frank Laski, Steven J. Taylor, Douglas P. Biklen, David Braddock, Robert Bogdan and K. C. Lakin. in the fields of "intellectual disabilities".
Community organising and development regarding the fields of mental health, traumatic brain injury, aging and children's institutions/private residential schools represent other forms of diversion and "community re-entry". Paul Carling's book, Return to the Community: Building Support Systems for People with Psychiatric Disabilities describes mental health planning and services in that regard, including for addressing the health and personal effects of "long term institutionalization". and the psychiatric field continued to research whether "hospitals" or community living was better. US states have made substantial investments in the community, and similar to Canada, shifted some but not all institutional funds to the community sectors as deinstitutionalisation. For example, NYS Education, Health and Social Services Laws identify mental health personnel in the state of New York, and the two term Obama Presidency in the US created a high-level Office of Social and Behavioral Services.
The 20th century marked the growth in a class of deinstitutionalisation and community researchers in the US and world, including a class of university women. These women follow university education on social control and the myths of deinstitutionalisation, 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.