Abstract
This article offers a comprehensive critical review of the most popular theoretical accounts on the recent processes of deinstitutionalization and reform of mental health services and their possible underlying factors, focusing in the sharp contrast between the straightforward ideas and models maintained by mainstream psychiatry and the different interpretations delivered by authors coming from the social sciences or applying conceptual tools stemming from diverse social theories. Since all these appraisals tend to illuminate only some aspects of the process while obscuring others, or do not fit at all with some important points of the actual changes, it is concluded that the quest for an adequate explanation is far from having been completed. Finally, some methodological and conceptual strategies for a renewed theoretical understanding of these significant transformations are also briefly discussed, including a comprehensive empirical evaluation of the facts, the consideration of the shifting social values and needs involved in mental health care provision and the historical analysis of deinstitutionalization policies within the framework of the broader social and cultural trends of the decades following World War II.
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Notes
For a paradigmatic summary of the official WHO guidelines for the reforms see Freeman et al. (1985).
Recently, some authors have rejected the word deinstitutionalization to describe this dehospitalization as inappropriate, because “it wrongly suggests that many settings were patients ended up were not institutional” (Geller 2000, p. 42). For a conceptual analysis of the term and other related issues see Bachrach (1976).
For an historical account on the development of social and community psychiatric thought and practices in England and the Netherlands during the postwar period see the volume by Gijswijt-Hofstra and Porter (1998); for the USA the best account remains Grob (1991); for Germany see Schmiedebach and Priebe (2004); and for Italy see Mollica (1985).
As successive milestones in the antimaniac, antipsychotic and antidepressant therapeutics, there must be mentioned, respectively, the introduction of lithium in 1949, that of chlorpromazine in 1951 and that of imipramine in 1957. See Healy (2002).
For a paradigmatic formulation of this account see for example Jones (1993).
One of the best-known studies on this missing correlation, which was quickly translated into other languages, was already published in the 1960s by the Norwegian epidemiologist Ødegard (1964).
There exists a remarkable historiographic consensus in dating the beginning of the generalized crisis of the mental asylum around 1860. See Scull (1984), pp. 104ff. for the Anglo-American sphere, and Castel (1976), pp. 282ff. for the French one. In the case of Germany, it was also during the first half of the decade of the 1860s when the well-known confrontation between W. Griesinger and some relevant representatives of the traditional asylum psychiatry took place. See Sammet (2000).
A paradigmatic formulation of this interpretation could be, for instance, the following one: “The chains are gone, the beatings are less frequent and more selective, the locked doors have been opened in many institutions, and the interior decorations have been improved. However, mental hospitals are still used primarily to confine disruptive members of the lower classes. The chains are chemical and legal, the beatings are psychological, and the locks have been replaced by members of the mental health team who guard the open doors” (Leifer 1969, pp. 98–99).
See for instance their critical analysis in overview works such as those by Goodwin (1997), pp. 33–36, and Forster (2000), p. 41. Among the historical studies that assume directly or indirectly this perspective, it is worth mentioning the already quoted monograph by Grob (1991) on postwar North American psychiatry.
In this case, the divisions reflected largely the interests of various influential subgroups within the psychiatric profession, such as the directors of mental health hospitals and university clinics, the neuropsychiatrists in private practice and the young professionals who pioneered social and community psychiatry. Until the definitive outline of the recommendations of the parliamentary commission (Enquête) in 1975, each of these groups made very divergent reform proposals. See Schmiedebach and Priebe (2004).
As a sample of this controversy, see the critiques made to Scull by Jones (1982) and his corresponding reply in Scull (1983). Along those years, many Anglo-Saxon journals such as the Millbank Memorial Fund Quarterly, the New Directions for Mental Health Services or the International Journal of Mental Health dedicated special issues to the development of deinstitutionalization. A second edition of Decarceration was released in 1984—it is the one quoted here—, and the author included then an interesting epilogue where he reviewed and replied to all the received critiques (Scull 1984, pp. 161–198).
Some years later, Scull summarized his interpretation as follows: “Given the reluctance to fund rehabilitation appropriate to the needs of the severely disabled, and the disincentives associated with income maintenance programs, one might conclude [...] that society has decided to ‘pay off’ the mentally ill rather than rehabilitate them—and to do so at near subsistence levels” (Scull 1985, p. 551).
It is interesting to note here that this correlation between labor shortage and psychiatric rehabilitation has been also proposed for the case of countries belonging to the old socialist bloc as the German Democratic Republic. See Schmiedebach et al. (2002).
Warner summarizes this dual interpretation of the process as follows: “Labor dynamics, then, may explain many features of the deinstitutionalization movement. Before the introduction of the antipsychotic drugs, the post war full employment in northern Europe required the rehabilitation of the marginally employable mentally ill, stimulating the development of more therapeutic styles of hospital care and a policy of early discharge. The move to milieu therapy and community treatment was delayed in the United States, where full employment did not generally develop. The introduction of disability pension schemes made possible the discharge of patients in the absence of employment opportunities, and the advent of antipsychotic drugs allowed the control of symptoms in patients placed in inadequate and stressful settings. These changes, particularly in the United States, led to a different style of community management—the transfer of patients to low-cost placements, often without genuine attempts at making patients productive, valued and integrated members of society’ (Warner 1994, p. 95).
Similar conclusions may also be valid for different mixed models that have enjoyed some diffusion, as it is the case of the account proposed by the English sociologist J. Busfield, who assumes a dual description of the process—creation of new services for mild or acute patients and transinstitutionalization for the most severe or chronic patients—that reminds the one by Warner, while her list of ‘underlying factors’ responsible for the bloom of the reforms combines arguments which are close to those of the critical accounts, to the economicist positions of Scull or to the medicalization hypothesis (Busfield 1986, pp. 342–346). Nevertheless, Busfield adds to this list another element that has not been mentioned here, but whose importance in the initial rhythm of the reform processes in some countries should not be neglected, i.e. the notable therapeutic optimism that pervaded psychiatry during the decades of the 1940s and 1950s: “This optimism, heightened though not initiated by the introduction of psychotropic drugs, stemmed from a number of sources: from the therapeutic developments of the period; from the increasing numbers of voluntary patients and those with less severe complaints using the mental hospitals; from the administrative reorganization of the services; and from the general climate of optimism of the period associated with post-war recovery and economic growth” (Busfield 1986, p. 344).
On this chapter of the history of psychiatry see, for instance, the excellent monograph by J. Braslow on the administration of somatic therapies in North American asylum psychiatry during the first half of the 20th century (Braslow 1997). An outstanding analysis of the process of medicalization experienced by French asylum psychiatry in the 19th century was offered by Lantéri-Laura (1972). For an overview of the “first biological psychiatry” developed in the traditional mental hospitals, see Shorter (1997), pp. 69–112.
The most emblematic landmarks of this official beginning of the psychiatric reform projects were the passing of the Mental Health Act of 1959 in the United Kingdom, the signing by J.F. Kennedy of the Community Mental Health Centres Act of 1963 in the USA, the delivery at the end of 1975 of the report of the Enquête-commission in the Federal Republic of Germany, and the passing in 1978 of the Law 180 for the case of Italy. See for example Forster (1997), pp. 36–62, for a synthesis of these and other relevant events in each of these countries.
Historical approaches to the postwar decades which emphasize the radicality and deepness of the economic, social and cultural transformations experienced during the period are offered in the known volumes by Hobsbawm (1994) and Judt (2005). It is certainly noteworthy that, in the course of a general work on the history of the 20th century as Hobsbawm’s one, the case of the community psychiatric reform programs is explicitly related to the consequences of social and cultural modernization (Hobsbawm 1994, p. 338).
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Acknowledgements
Preparatory research for this paper was conducted during two academic stays at the Universities of Berlin (FU) and Hamburg funded by the German Service for Academic Exchange (DAAD) and the Medical Research Foundation MMA (Spain). I am also very grateful to Professor Heinz-Peter Schmiedebach, Dr. Kai Sammet and two anonymous reviewers of this journal, who read an earlier draft of the manuscript and provided valuable critical insights.
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Novella, E.J. Theoretical accounts on deinstitutionalization and the reform of mental health services: a critical review. Med Health Care and Philos 11, 303–314 (2008). https://doi.org/10.1007/s11019-008-9123-5
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DOI: https://doi.org/10.1007/s11019-008-9123-5