Psychiatry Of Deinstitutionalization Research Paper

1. The Rise Of The Asylum

One of the oldest psychiatric institutions in the West is the Bethlem hospital, founded as a priory in 1247 and used to house the mentally ill from 1403 to the present day. Its name, corrupted to Bedlam, attracted the stigma that became an inescapable feature of such institutions and was used to vilify the psychiatrically ill as bedlamites. Similar hospitals were established throughout Europe and North America in the ensuing centuries but the massive expansion of psychiatric hospitals, or asylums as they became known, did not occur until the nineteenth century. In the UK this was as a result of government policy to provide each county with at least one public asylum, as legislated in the County Asylum Act of 1808. Large sums of money were made available for the asylum building program, of which the Victorians were very proud. Considerable effort went into the design of the buildings, with particular attention to the circulation of air through-out the asylum and to the external decoration.

Asylums were usually sited some miles outside of towns or cities: far enough away to avoid disturbing the public, but near enough to facilitate the transport of patients. Friern Hospital was constructed on a rural site north of London and the nearest railway line was extended to make it accessible. The hospital was opened in 1851 by Prince Albert, the husband of Queen Victoria, and was designed to house a thousand patients. It rapidly filled up and its population continued to grow way beyond the original limit, reaching a peak of 2,400 a century after its inauguration. This rapid expansion was a general feature of asylums. Once a place of containment became available, the opportunity was seized to expel from society people with a wide variety of problems who were seen as undesirable. These included people with developmental disabilities, who were sometimes sent to segregated institutions and sometimes mixed indiscriminately with the mentally ill. There were even instances of women bearing illegitimate children who, when pregnant, were sent to such institutions where they spent the rest of their life.

As their populations grew steadily, the asylums became increasingly overcrowded, until they reached the point where the beds were so close together that patients had to climb over others’ beds to reach their own. Overcrowding generated squalor, and since the staff were unable to cope with the large number of disturbed patients, it was almost inevitable that abuses occurred. The public scandals that ensued hastened the demise of the asylums, but before charting their decline it is worth considering how they functioned in their heyday.

The typical asylum was either a very large building or a collection of villas set in extensive grounds which were surrounded by a high wall with a single entrance guarded by a gate lodge. Within the walls were vegetable gardens and often a farm with cows and sometimes pigs. Some asylums had their own artesian wells and many were virtually self-sufficient or even produced a surplus. Powick hospital in the west of England during the 1920s was selling one thousand bushels of wheat and 1,800 pounds of beef per year. The patients provided the labor to work the farms, as well as helping in the hospital kitchens and the laundry. The use of unpaid patient labor was viewed by the trade unions in the West as exploitation and it ceased in most hospitals in the mid-twentieth century. When patient labor was replaced by a paid professional workforce, activities for the patients had to be organized. These took the form of recreational activities, designated as occupational therapy, and work-like activities, often termed industrial therapy. Industrial therapy ranged from simple repetitive tasks such as assembling darts to complex procedures such as making furniture designed by the staff. The industrial therapy unit at Friern Hospital, at its peak, employed 120 people, some of whom commuted daily from their homes since nothing comparable existed in the community.

2. The Turning Point

In the UK the number of psychiatric beds climbed steadily for more than a century, reached a peak of 149,000 in 1954, and since then has fallen progressively. A similar pattern occurred in the USA, where the number of residents in state psychiatric hospitals declined from 186 per 100,000 in 1969 to 33 per 100,000 in 1992. Psychiatric bed occupancy has also been falling in most Western European countries since the 1970s but the rate differs by country. In Italy the number of psychiatric hospital beds rose from 36,000 at the beginning of the century to a peak of 188,000 in 1971. Since then there has been a steady decline to 7,500 in 1999, including both state and private hospitals. In Israel the number of psychiatric hospital beds has fallen from more than 11,000 to 6,000 in 1999. Four factors can be identified that prompted this change: the introduction of specific antipsychotic drugs, abuse of patients by staff that provoked public scandals, critiques of institutions by sociologists and others, and a change in the attitudes of psychiatrists.

It has been claimed that the key factor was the advent of antipsychotic drugs, but that cannot be the only answer since chlorpromazine, the first of the genre, came into general use in 1955, whereas in some pioneering psychiatric hospitals in the USA and UK the bed numbers began to fall in the late 1940s. By controlling disturbed and unacceptable behavior, the drugs certainly facilitated the process of deinstitutionalization, but they did not initiate it. Similarly, public scandals gave a high profile to the problems of institutions and helped to mobilize a search for alternative forms of care, but did not start the process.

Academic books criticizing psychiatric institutions began to appear at the end of the 1950s and certainly exerted some influence on the attitudes of psychiatrists and other staff. The first was by a psychiatrist, Russell Barton, and appeared under the title Institutional Neurosis in 1959. The term he invented was inappropriate since the great majority of patients adversely affected by institutional living suffered from psychotic illnesses. However he accurately described the apathy, inertia, lack of motivation and affective poverty which characterised long-stay patients in institutions. This was followed by a particularly influential book by Erving Goffman (1961) entitled Asylums. Goffman spent a year in the late 1950s observing interactions in a US psychiatric hospital. He described the humiliating rituals which were inflicted on new entrants and saw their main purpose as being to sever all links with the everyday world outside the institution. He coined the term ‘total institution’, which he defined as ‘a place of residence and work where a large number of like-situated individuals, cut off from the wider society for an appreciable period of time, together lead an enforced, formally administered round of life.’ Asylums certainly provided accommodation and work, but in addition many supplied every amenity likely to be required in everyday life, including a place of worship, a patients’ club, hairdressers, and shops, so that there was no need ever to leave the confines of the hospital.

These books, however seminal, appeared in print too late to explain the fall in beds in the pioneering asylums. For example, Dr. Duncan Macmillan, who occupied the unique position of Medical Officer for Mental Health for Nottingham, UK, established an outpatient clinic in the local general hospital in 1932. Later he became Physician Superintendent of the psychiatric hospital, Mapperley, and by 1957 the senior members of the hospital’s medical staff were spending over 50 percent of their time in 34 clinics in the community. As a consequence of these developments, the number of inpatient beds began to fall in 1949.

World War II seems to have provided psychiatrists with experiences that led to innovative experiments in therapy. This entailed the recognition of the legitimacy of fear in the face of appalling danger, and affected soldiers were treated with psychological approaches. Military psychiatrists saw healthy young men break down with severe psychiatric syndromes under stress, and then recover when treated in group settings. In these military centers every aspect of the regime was designed to counteract the development of chronicity. At the end of the war, the army psychiatrists, imbued with optimism about the potential for recovery, took up posts in the psychiatric hospitals. They included British pioneers such as Maxwell Jones (1952) who founded the Henderson hospital as a therapeutic community for people with psychopathy, and Tom Main, who took over and transformed the Cassell hospital. As directors of psychiatric hospitals, these charismatic men had the power to make their vision a reality, unimpeded by bureaucratic inertia. However, they had to fight the resistance of other members of staff, who were often more institutionalized than the patients.

In the USA the impetus for attitude change also arose from the war, but from a surprisingly different source. Conscientious objectors were obliged to do public service in psychiatric hospitals. They brought into these institutions a humanitarian attitude which had not been dulled by the hospital regime. Furthermore, as they had no professional training, they treated the patients as equals and as valued individuals. The ferment they introduced into the system worked its effects on the professional staff.

3. Decline And Fall Of The Psychiatric Hospital

Once the antipsychotic drug, chlorpromazine, became available, the handful of pioneering hospitals were joined by the rest in discharging patients in large numbers, and a steady decline in the number of occupied beds occurred in the USA and in England and Wales. This was not observed in Scotland, which had a separate health administration. The decline in England and Wales was so steady over a number of years that Tooth and Brooke (1961) predicted that the existing long-stay population of psychiatric hospitals would be eliminated through discharges and deaths by the year 1986. The reasons their prediction proved to be wrong are of considerable import. First, some patients admitted to acute wards remained in hospital for over a year. They were termed the ‘new long-stay’ in distinction to the old long-stay who were a relic of custodial care. Of course the distinction between the two is arbitrary depending on the point in time when observations are made. The significance of this group is that their problems are clearly not created by the institution but are a consequence of their psychiatric illness. Hence closure of the institutions will not abolish the ‘new long-stay.’ The second group of patients that confounded Tooth and Brooke’s pre-diction are those whose behavior is so disturbed and disturbing that they cannot be moved to homes in the community. These ‘difficult-to-place’ patients pose a major challenge to deinstitutionalization and will be considered in more detail later.

Despite these problems, the run-down of the asylums has progressed to the point where many of them have been closed. In the USA the number of state psychiatric hospitals decreased from 277 in 1970 to 231 in 1996. There has been an even more dramatic change in England and Wales where 100 of the 130 psychiatric hospitals have closed since 1980. In Italy the closure of the institutions was achieved by revolution rather than evolution. In 1978 the Italian parliament passed Law 180 which prohibited the admission of patients to psychiatric hospitals thence-forth. This legal constraint on admissions did not directly affect the patients already resident in the asylums, and it took many years to improve their conditions of life.

Law 180 reminds us that changes in psychiatric services cannot be carried through by staff alone. They require the backing of the government of the day to provide the financial resources necessary to create and develop new services. The Italian law was pushed through parliament by the Communist party, whose support was recruited by Franco Basaglia, a charismatic psychiatrist and founder of the Democratic Psychiatry movement. In the UK there was no political polarization over deinstitutionalization. The closure of psychiatric hospitals was heralded by the Conservative Minister of Health, Enoch Powell, in a famous speech in 1961 in which he referred to the asylums as ‘isolated, majestic, imperious, brooded over by the gigantic water-tower and chimney combined, rising unmistakeable and daunting out of the countryside.’ Successive governments, whether of the right or the left, continued to endorse the policy, but with different agendas: the left supported patients’ rights for ideological reasons, while the right hoped to save money by closing the old asylums.

4. Alternatives To The Psychiatric Hospital

Where were patients to live when they were discharged from an asylum? Wherever the process of discharge has been studied it has emerged that the least disabled patients were selected to move out first. Many of these patients were able to cope in independent accommodation. As the more dependent patients were considered for discharge, it became evident that they needed supervision in their community homes. For the most disabled patients, 24-hour supervision was required. The closure process for two London psychiatric hospitals, Friern and Claybury, was studied by the Team for the Assessment of Psychiatric Services (TAPS) over 13 years (Leff 1997). TAPS found that 78 percent of the long-stay patients were discharged to staffed homes. In the USA, Eileen Rothbard and her colleagues (1999) monitored the closing of Philadelphia State Hospital and found that 75 percent of the long-stay population were living in residences with 24-hour staff supervision. Intensive staffing in-variably carries a high cost, since over 80 percent of the cost of care in the community is contributed by staff salaries.

The obvious choice might seem to be to resettle patients with their families, but this is rarely achieved for the long-stay patients. In the Friern and Claybury programs only 4 percent of them returned to their family home. This is partly due to loss of contact with relatives over the course of decades in an institution, which had occurred to 75 percent of the Friern and Claybury patients. The other reason is that a high proportion of patients are experiencing active delusions and hallucinations which are not controlled by medication and require specialized care.

In many of the resettlement programs, the more disabled patients live in small groups in ordinary houses, indistinguishable from neighboring buildings. This has an obvious advantage in easing reintegration into the community. However there are barriers other than distinctive architecture, which became apparent from the TAPS evaluation. Nearly 700 long-stay patients were followed up for five years after discharge to homes in the community. Although there was no amelioration of their psychiatric symptoms or problems in social behavior, they did acquire skills in caring for their homes and in using community amenities. Compared to the hospital wards, they enjoyed much greater freedom in their homes, which they greatly appreciated. When asked where they wanted to live, 84 percent preferred to stay in their current home, and almost all those who wanted to move wished to live independently. Only a handful desired to return to the hospital.

Beneficial outcomes for long-stay patients dis-charged from psychiatric institutions have been re-ported by other researchers in the UK and the USA, although few have studied a large sample of patients over a long period of time. An exception is Courtney Harding and her colleagues (1987) who conducted a 32-year follow-up of 269 patients discharged from Vermont State Hospital, USA in the 1950s as part of an experimental rehabilitation program. The findings were that over half the patients were functioning much better than expected.

One drawback to life outside the asylum that TAPS revealed was the failure of most patients to develop social relationships with their neighbors. Undoubtedly the impairment of social skills by schizophrenia was contributory, but it is not the whole story. Most of the patients were resettled in cities, where there is not a strong sense of community and even healthy neighbors have little to do with each other. Geoffrey Wolff and his colleagues (1996) mounted an experimental study of an education campaign in a street in which long-stay patients from a south London asylum were resettled. The campaign was successful in reducing neighbors’ fear of the mentally ill and in increasing their social contact with the new residents.

Another problem is the lack of employment prospects for people with a long history of psychiatric hospitalization. When the national unemployment rate is high, it is almost impossible for someone with such a history to obtain a job. One solution is to establish cooperatives, or ‘social firms’ as they are sometimes known. These are particularly well-developed in Italy, and a comparison of people with schizophrenia between Boulder, Colorado, and Bologna, Italy (Warner et al.1998) showed that the Italian patients worked for more hours and earned more than the US patients. The development of employment opportunities for mentally ill people in the community needs far more attention than it has received to date, as it is one of the prime means of social integration.

5. Is Community Care Affordable?

It is not difficult to provide cheap community care. There have been several low cost schemes to house discharged patients in the USA and the UK. In the USA, ‘board and care’ was an inexpensive way to provide patients with accommodation, but very little else. The proprietors of these homes ran them as commercial enterprises and had little or no instruction in the care of the patients. It is hardly surprising that patients were treated extremely badly in some cases, giving rise to public scandals. In the UK, patients were placed in seaside boarding houses, many of which are empty during the winter and would otherwise have closed until the summer season. Hence the offer of permanent residents all the year round was attractive to their owners. However, no provision was made for the patients’ work and leisure needs, and television documentaries showed pathetic scenes of patients wandering along deserted windswept promenades in the driving rain. Patients placed in these seaside towns were even further from their districts of origin than when in the asylums.

The crucial question is how a good system of community care compares with hospital care in terms of cost. There have been very few attempts to make this comparison. The TAPS project involved a collaboration with a team of health economists who carried out a detailed costing of all services used by the long-stay patients when in Friern and Claybury hospitals and then when they had been in the com-munity for one and five years. As this was done prospectively, the costs for specific individuals can be compared over time, adjusting for inflation. For all the discharged patients, the cost in the community after the first year was slightly less than their cost when in hospital, although the community costs rose slightly by five years (Leff 1997). However, not all the long-stay patients were discharged to community homes. A sizeable group were considered to be too disturbed to move to the community. When the hospital closed these difficult-to-place patients were transferred to highly staffed facilities, mostly on other hospital sites. The high staffing levels made their care very expensive, so that when they were added into the cost equation, community care became more expensive than care in the hospital had been.

By contrast, a costing exercise by Eileen Rothbard and her group (1999) for patients discharged from Philadelphia State Hospital showed that community care was considerably cheaper than the estimated cost of hospital care. Cost comparisons on their own are insufficient: what is needed are cost-benefit analyses across sites and countries.

6. Critiques Of Deinstitutionalization

Criticisms have come from within the psychiatric profession and from outside, mainly from the media, from disgruntled family members, and from citizens who object to sheltered homes being established in their neighborhood. One of the most stringent professional critics has been Harold Lamb (1976) in the USA who has pointed to the large number of severely mentally ill people who are in prison. He argues that patients have been transferred from a relatively benign institution, the psychiatric hospital, to a punitive one, prison, and has dubbed this process ‘transinsti-tutionalization.’ Two related issues are raised by his critique: does community care inevitably lead to the imprisonment of the mentally ill, and are the mentally ill more dangerous than the average citizen? In the TAPS study, of the 670 patients followed up for five years after discharge only five spent time in prison, while 13 (2 percent) committed assaults on others. In the study by Eileen Rothbard and colleagues (1999), 2 percent of the 321 long-stay patients followed up for three years were involved in the criminal justice system. Thus it appears that a well-organized and funded community program does not lose many patients to prison, and furthermore that the great majority of mentally ill people are not dangerous. Unfortunately the media prefer to highlight the few tragic homicides that do occur, hence reinforcing the public stereotype of the ‘mad axeman.’ It is this irrational fear that fuels the ‘not in my backyard’ attitude of some members of the public. Geoffrey Wolff and his colleagues (1996) have shown that a localized educational campaign can reassure neighbors about ex-hospital patients coming to live in their street.

The other concern of the media and the public is that many patients discharged from long-term care end up on the streets. While the number of homeless mentally ill has undoubtedly increased, several surveys have found that very few of them have spent much time in psychiatric institutions. In support of this observation, less than 1 percent of the TAPS sample became homeless over five years and only 2 percent of the Philadelphia State Hospital ex-patients over three years. While no mentally ill person should be without a home, the problem stems from the inadequacy of aftercare for those coming out of admission units and not from the long-stay patients who are resettled in sheltered residences.

This raises the question of the balance of resources to be invested in community care programs. The asylums represent a large investment of capital, in the land and buildings, and of revenue, in staff salaries. The value of the site is often considerable since urban expansion has incorporated the once distant asylums. Various financial strategies have been used to release the capital and revenue bound up in the asylum, so that they can be reinvested in providing a good quality service for the long-stay patients. But patients with long-term disabilities continue to arise in a population and need the kind of rehabilitation facilities which used to exist in the psychiatric hospitals but have generally not been re-provided in the new services. Additionally, the care of acutely ill patients is be-coming increasingly difficult with the ready availability of street drugs. It seems to be difficult for funders to invest in acute and rehabilitation services at the same time as providing for the long-stay patients coming out of the institutions. Within North America and Europe, only Finland seems to have achieved a reasonable balance between these two sectors. With-out such a balance, it is not surprising that family members are discontented with the service offered to their acutely ill relatives, and that deinstitutionalization has become the target of criticisms that should justly be directed at the failure to provide a comprehensive psychiatric service of a uniformly high standard.

Bibliography:

1. Etzioni A 1961 A Comparative Analysis of Complex Organizations. Free Press of Glencoe, New York
2. Goffman E 1961 Asylums: Essays on the Social Situation of Mental Patients and other Inmates. Anchor Books, Doubleday, New York
3. Harding C M, Brooks G W, Ashikaga T, Strauss J S, Breier A 1987 The Vermont longitudinal study of persons with severe mental illness, II: Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. American Journal of Psychiatry 144: 727–35
4. Jones M 1952 Social Psychiatry: A Study of Therapeutic Communities. Tavistock Publications, London
5. Lamb H R 1976 Community Sur i al for Long-Term Patients. Jossey Bass Publications, San Francisco
6. Leff J (ed.) 1997 Care in the Community: Illusion or Reality? John Wiley, Chichester, UK
7. Rothbard A B, Kuno E, Schinnar A P, Hadley T R, Turk R 1999 Service utilization and cost of community care for discharged state hospital patients: A 3-year follow-up study. American Journal of Psychiatry 156: 920–7
8. Tooth G C, Brooke E M 1961 Trends in the mental hospital population and their effect on future planning. Lancet I: 710–13
9. Warner R, de Girolamo G, Belleli G, Bologna C, Fioritti A, Rosini G 1998 The quality of life of people with schizophrenia in Boulder, Colorado, and Bologna, Italy. Schizophrenia Bulletin 24: 559–68
10. Wing J K, Brown G W 1970 Institutionalism and Schizophrenia: A Comparative Study of Three Mental Hospitals 1960–1968. Cambridge University Press, Cambridge, UK
11. Wolff G, Pathare S, Craig T, Leff J 1996 Public education for community care: A new approach. British Journal of Psychiatry 168: 441–7