History of Mental Health 101: Deinstitutionalization and Comunity Care

Foreword


History of Mental Health 101 is a set of articles that reviews the history of mental health from a sociological perspective: from the ancient to the modern understanding of the concept. Nowadays, mental health is one of the most widely discussed topics; however, it had a hard, alluring history of development through centuries. The following six articles explore the history of mental health and some of the most fascinating and sometimes unbelievable facts about the topic, aiming to raise awareness about mental health and its importance of one’s wellbeing.


  1. History of Mental Health 101: Mental Illnesses and Demons

  2. History of Mental Health 101: Is there a Healthy Mind in a Healthy Body?

  3. History of Mental Health 101: The First Asylums

  4. History of Mental Health 101: Chlorpromazine and the Drug Revolution

  5. History of Mental Health 101: Deinstitutionalization and Comunity Care

  6. History of Mental Health 101: Stigmatization of Mental Health

  7. History of Mental Health 101: Mental Health in an Unequal World


Deinstitutionalization and Comunity Care


Problem Inside the Institutions

For years mental hospitals and asylums were the only options for mentally ill people and their family members to seek help related to their illness. As believed, the inpatient care model (patients living in the hospital) was the most effective approach to mental health treatments, as they were under constant observation of professional staff. Institutionalization was actively used by families who could not afford to take care of their mentally ill family members; therefore, the number of patients in the state hospitals was increasing rapidly, and soon there were more patients than the hospital facilities and the professional staff could handle. This resulted in a deteriorating quality of care, living conditions, and abuse of human rights in the hospitals (Novella, 2010).


The danger inside of institutions was observable on several levels, one of which, mortification of self, was described by Erving Goffman. In 1961, Goffman wrote his seminal work, Asylum, where he discussed the problematic influence of asylums on patients, coining the term “total institutions” (Goffman, 1961). As discussed in his book, mental hospitals were akin to prisons, concentration camps, and/or monasteries; however, patients and inmates of these institutions had no criminal record or problem with the law. He defines psychiatric institutions “as a closed system apart from the rest of society”, where patients lived secluded from the outer world under the active process of mortification of self. All the activities were performed within a large group of inmates and a sense of identity was gradually decreasing among patients. Mortification of self was done through physical and mental abuse, as individuals were stripped of their past roles and were assigned the labels of institutional life (Chow, 2013).


Figure 1: Erving Goffman

By all means, mortification of self was not the only problem inside the mental institutions. In the 1840s, journalist and activist Dorothea Dix witnessed the danger and cruelty inside the mental hospitals; as a nurse working in different institutions, she encountered brutal conditions inside these institutions, which she described as patients "in cages, closets, cellars, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience" (Roth, 2018). That was the reason why she dedicated part of her life to improving the living conditions of mentally ill people and helping those in need (Unite for Sight, 2020), making it her life goal to advocate for people with mental illnesses. She traveled all across the United States, gathering information and statistics about different institutions - it took her approximately 40 years to convince the US government to build 32 state psychiatric hospitals (Nelson, 2021).


Dorothea Dix, portrait by Samuel Bell Waugh, 1868.
Figure 2: Dorothea Dix

The issue was not solved here, however. Various other movements were inspired to defend the rights of mentally ill people - to speak up against the human rights violations in mental hospitals and to create global movements advocating for deinstitutionalization across the world. Based on a belief shared by all those activists, patients would heal faster if they were under community and home care, instead of large institutions filled with patients. Also, this transition from asylum-based care to community care would be made easier by the drugs and procedures that were being developed around these years (Unite for Sight, 2020).

The Reality of Deinstitutionalization

The effort of these movements paid off: according to World Health Organization, the transition from asylum-based care to community care was actively performed in the last 50 years. The goal of deinstitutionalization was to integrate mentally ill individuals into society and empower them. Although, it was only a small portion of patients who enjoyed the benefits of deinstitutionalization, such as proper social integration, employment, independence, and avoidance of rehospitalization; those were the patients who had a strong social background and someone to take care of them. Unfortunately, the majority of the patients, who had less support in society, suffered the consequences of deinstitutionalization (Read, 2009).


Deinstitutionalization of Mental Health Care
Figure 3: A patient in a Mental Health Care facility

Many patients moved from hospitals to homes that were not properly equipped to meet the requirements for mentally ill patients. Also, the burden of taking care of the mentally ill individual moved from professional staff to family members, or those who were not specialized to take care of the patients. In short, families with mentally ill members suffered from financial and physical overload, as they did not have the skills to treat their family members (Novella, 2010). Apart from insufficient resources for adequate community/home care, another issue was the decrease in the quality of institutionalized care. Those patients who were hospitalized due to deterioration of mental health were discharged in a short period, usually after 15 days, even if the condition was not stable, and from 10 to 20 percent of those patients were readmitted within 30 days (Fayerman, 2008).


Many studies demonstrate controversial findings around the topic. Some of them, with positive findings, speak about improved social skills in the community care system, such as building connections and friendships, and more, general satisfaction with their social life (Martinez-Leal et al., 2011). However, other studies describe the problem of poverty and loneliness in community care and highlight the issue of deteriorated medical care, as patients could not afford regular medical checks, cancer screenings, and vaccinations (Novella, 2010). The situation was even harsher for those patients who had no families or guardians, as they were excluded from the benefits such as integration into the community and employment. As a result, many would end up in the streets, without money or housing. A study carried out by the Canadian Mental Health Association designed to explore the life of patients after deinstitutionalization, found that 30-35 percent of Canada’s homeless people were mentally ill. This study also demonstrates that approximately 50 percent of psychiatric patients had dual diagnoses, meaning that they had coexisting drug or alcohol addiction. Needless to say, without proper treatment, the lives of these people are in danger (Canadian Mental Health Association, 2005).


Figure 4: Vancouver Downtown Eastside (DTES)

Possible Solution

Every patient needs a different model of care based on the nature of their mental illnesses. For instance, some patients who are prone to self-harm or different addictions might benefit from controlled institutionalized care. Moreover, in the cases of granting the right to home/community care to the patient, the institution must make sure that the individual will have adequate conditions after being discharged from the hospital - in other words, community care centers must provide support and professional care to the patients. There are some bright examples of dealing with the issue successfully, e.g. the Burnaby Center for Mental Health and Addiction, which offers help to up to 100 individuals in need (mental problems, drug or alcohol addictions) and takes care of their reintegration into society. However, those approaches are not applied everywhere. “There needs to be a balance between independence and support; it is apparent from the current mental health situation that this balance has not been achieved” (Read, 2009).


In conclusion, in the 1950s deinstitutionalization was envisioned as the only possible solution to end the suffering inside the mental institutions. After active campaigns around the globe, patients were admitted to receive treatment at home or in community care centers. However; the results were different from the expectation. Poor conditions and insufficient resources caused by community care put mentally ill people at the risk of poverty, homelessness, drug or alcohol addictions, and even suicide.



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Irina Berdzenishvili

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