So anti-psychiatry is in the background and a major change is about to happen in mental health care. Deinstitutionalization. Deinstitutionalization resulted in many people who'd been in long term patients in psychiatric facilities being discharged into the community. We often focus on that aspect of it, but deinstitutionalization also refers to the fact that we began to shorten the length of stay that people had in hospitals generally. And there was a decrease in the number of beds that were available for psychiatric care. The, the deinstitutionalization that I'm describing really refers to the experience in North America. In other parts of the world, there had been similar movements towards less confining methods of providing care. However, not all countries had invested as heavily in institution-based care as the US, Canada, and to some extent the UK. So in other places, deinstitutionalization was far less dramatic. Also, it's important to note that while the number of people being institutionalized for psychiatric care has dropped in much of the world. There are some places where institutionalization has actually increased after long histories of not having institutional based care. So, let's talk about what happened in the Western context. As we move into the early decades of the twentieth century, we had seen many changes that opened up new options for dealing with mental illness. the growing confidence in a scientific model for dealing with mental health problems had shifted the emphasis in care from isolating people with mental disorders to treating them. This change was signaled by the shifting nomenclature for mental health care institutions, now called hospitals rather than asylums. And, starting around the 1950s, new medical treatments became available, drugs like antipsychotic medications, antidepressants, mood stabilizers, and major tranquilizers offer the possibility of reducing psychiatric symptoms and enabling people to function outside of hospitals. Another important development was the introduction of psychotherapies as a treatment for mental illness. In Europe, pschotherapy and especially psychoanalysis had been used for a long time, but the wide use of these psychotherapies came later in North America and the 50s and 60s saw much more widespread use of psychodynamic and other therapies to treat people, somtimes independently or as an addition to treatment with medications. So those, were some of the positive things going on that made deinstatualization of the mental health care system possible. At the same time, there were also some negative things happening, that would push the system towards deinstitutionalization, Some of those you've already heard about in the anti-psychiatry lecture, so we knew, we know that there where treatments going on at the time that were actually quite harmful to patients and that was being brought to the attention of the public. even we've mostly focused on the shock therapies and on lobotomies, but as I already said, even the the medications themselves could be problematic and certainly psycho ex-patients that were talking about their experiences in the mental healthcare system were quite vocal about what they saw as the harm that those treatments had done to them. I've also already mentioned other abuses within psychiatry that were reaching public attention. one that is particularly relevant in Canada is the work of Dr. Ewen Cameron, who in the 50s was exposing psychic, psychiatric patients to LSD and high levels of electroshock therapy as part of mind control experiments for the CIA. These patients did not consent to this and suffered significant damage from it, and unfortunately, this work was repeated in other parts of the world. so internationally there were stories circulating about psychiatrists and psych, psychiatric hospitals that really diminished the trust that the public had in mental health care facilities. This together with another period of declining investment in psychiatric institutions certainly helped to set the stage for transferring the care of people with mental illnesses away from such places. So deinstitutionalization, you see, refers to the shifting of care for people diagnosed with mental illnesses from psychiatric facilities where they were receiving long term care to receiving care in the community. The vision is that these former patients now better able to function because of the availability of new treatments that they should be capable of living independently in the community. Deinstitutionalization was the result of the conversion conversions of forces and events. we conventionally refer to, to it being stimulated by the introduction of new drugs as I've already mentioned. and this was especially liberating for people with psychotic disorders like schizophrenia, because they had been a group of patients often left to languish, languish in psychiatric institutions. There was also a lot of legal advocacy that prompted deinstitutionalization by asserting that patients had the right to be treated using the least restrictive alternatives for care. The 50s and 60s was a time of important legislation around the conditions under which people could be confined to psychiatric institutions and they laid down early versions of mental health acts that would determine involuntary treatment was only permissible when someone was a danger to themselves or other. activism was also important in pushing towards the institutionalization because of the anti psychiatry movement, the consumer survivor movement, the disability rights movement. All in various ways they criticized in, institution-based psychiatric care and advocated for the self-determination of people diagnosed with mental illnesses. So, you'll see these kind of numbers all over the internet in terms of like, if we think about in the U.S. in 1955, there were almost 600,000 people institutionalized and there was a population of a 165 million. Then we go to 1998 where there are now only about 60,000, so it's dropped by 10% at a time when the population has increased quite a bit. So there are some other explanations for why deinstitutionalization was able to happen at that time. There are some that would suggest that there were economic reasons why there was a deinstitutionalization. as I've already mentioned, the system was in another period of withdrawn investment and the cost for running institutions had risen, not only because everything was more expensive, but because they could no longer rely on unpaid patient labor to make the places run. Some suggest that discharging patients from institutions was a move to save money. It was much cheaper to neglect them in the community than to take care of them in institutions. Now this is an argument that doesn't really hold up very well if you look at it carefully, because community care is not actually less expensive than institution, institution-based care. but but certainly there are some people who believe that that is one of the motivations is that it was just better for the bottom line. There's another set of arguments that we'll talk about, the shift to an emphasis on accute care instead of chronic care. So there was a shift of resources, so that instead of devoting most of our energy to patients with chronic and long term illnesses there was more attention being paid to dealing with accute care and treatment in general hospitals and primary health care settings. So this was also for the signaling of shift in the, in the expansion of the scope of mental health practice. so it was no longer just concerned with people who were severely ill and, and significantly disabled, but also with people who are at, who are at other places on the spectrum. So there definitely was a shift to attention for acute care and that certainly would have contributed to more of an emphasis on services in the community rather than institutions. Another important change was the shift toward a biopsychosocial model of mental health care that suggested psychological and psychosocial treatments were as important as medical and pharmacological treatments. So the increasing use of psychotherapy and psychosocial rehabilitation, which I will talk about more in the next section really meant that people needed to be out in the community, because, actually being in the community was being part of, was part of the treatment. So again, having other options for treatment and seeing community placement as part of that treatment was another reason why deinstitutionalization, was poised to happen. Now, Randall Krieg in a paper that I've, we'll attach in the resource section, sorry, I'll attach the reference for it in the resource section, took a look at deinstitutionalization using what he called a stakeholder analysis in an attempt to explain why deinstitutionalization is something that most people agree was a positive change but really has such an ambivalent, has been such an ambivalent experience. So, in his paper, he suggests that from the perspective of patients or consumers of psychiatric services, deinstitutionalization was a very positive move away from a paternalistic system in which almost everyone is assumed to be a better judge of their best interests than they were to a system that was prepared to engage with them based on their self-determination and so pre-existing institutionalization as mostly a win for consumers of psychiatric services. He is less positive about its effects for the community that ended up receiving the institutionalized patients. He asserts that when patients were no longer institutionalized, communities became exposed to threats from which the institutions had previously insulated them. He describes ex-patients as a threat to the security and stability of communities and feels that community members being exposed to homelessness, for example, is a negative effect of deinstitutionalization. Now, I'm not in complete agreement with this because first, the belief that having people with mental illness in the community increases violence and instability really doesn't hold up if you look at the research. In fact, people with mental illnesses are far more look like, far more likely to be victims of violence than members in the general public. Also, the communities exposure to homelessness is not a problem that really originates with ex-patients. It's a problem that originates with inadequate housing resources and lack of access to affordable housing and those problems affect many groups, frankly any group that is low income. So while I would not deny that these problems exist, I do object to them being attached to people diagnosed with mental illness as if they are the entire or exclusive cause of them. I find it easier to agree there's a suggestion that community members have been forced to face tough questions about what is their obligation to care for people among them, since institutionalized care was one way of removing them from that responsibility. You may remember that the Canadian National Committee on Mental Hygiene exhibit was very much about telling the community. You don't have to worry about this, we'll take care of it, we'll take it far away from you and your neighborhood. So once the institutions started to close down and a number of hospital beds were reduced, people in communities were really forced to consider what support they were willing to extend to these members of their communities. Finally, the community is also affected by the fact that there is no cost saving in transferring institutional care to the community. Care and support services simply need to be transferred to other organizations and what we have seen is that a wider range of services required, is required, so the health care system cannot manage the needs of people with mental illnesses without supporting collaboration from other systems like housing, education, employment, family services, and social services. Krieg also takes a look at family members and talks about an ambivalent experience for them, which we're going to talk about when we have our lecture about families and mental illness in more detail. But certainly deinstitutionalization meant that care was taken up by family members and not necessarily with enough support. And there's a huge literature that talks about the burden of being a caregiver for somebody who is diagnosed with a mental illness. And we, we do of course, want to bounce that against the fact that family members have been cut off from their loved ones through much of the history of mental health care. And so there was some burden, but there was also some value for some people in having their family members back with them and being sort of invited into that circle again. But yes, an ambivalent experience. So maybe it's hard for us to know completely what motivated the deinstitutionalization, but I think it's unquestionable that challenging the system to provide care in the least restrictive means was an important gain for human rights as was the development of the legislation that increased accountability around the reasons for involuntary admission to psychiatric institutions, and increase the accountability for insuring the patients participated in treatment under conditions of self-determination and informed consent. The problem with deinstitutionalization was that it happened before community services were in place to replace the institutions. We locate deinstitutionalization in the 1950s, but they had actually started large scale discharging of patients from institutions as early as a decade before that. But, resources stayed with the institutions, even though the patients were leaving, and I remember that even when I started working in psychiatry in the 90s, early 90s,90s, yes. We were still talking about the fact that a lot of the money and the resources were still with hospitals, when they had been promising and promising, basically since the 50s, that it was going to be shifted to the community. So the consequences of that were that people who needed treatment weren't getting it. Others were getting treatment, but not really getting full benefits from it. And in the community environment, there were ongoing symptoms that made it difficult to cope and the, these patients did not have the predictable controlled environment of a hospital to make that easier. Many patients weren't able to sustain themselves in independent living situations, and so, and they needed support of housing that simply wasn't available. This contributed to the homelessness that Krieg talks about. This also contributed to criminal justice involvement for people with mental illnesses. There are many studies that show large percentages of people incarcerated in the crimical, criminal justice system have diagnosable mental illnesses. Certainly mental illness doesn't discriminate and people who commit crimes can have a mental illness as well, but we believe that many of these people end up in trouble with the law because of inadequately treated mental illnesses. If they were well, would they have gotten into situations that led to their incarceration? It's not an easy question to answer, but it's one that we certainly have to ask. Krieg also alludes to the burden on families and communities and lack of institutional care and community services has certainly increased the amount of labor that has been required of, of family members. we'll talk more about this in the week on families and mental illness, but there's an extensive literature that takes about, talks about the toll that care giving takes. And the feelings that families have that the system really abandoned them and their relatives with diagnoses. Finally, not everyone is enthusiastic about the benefits that deinstitutionalization has had for people who are diagnosed with mental illness. Many patients benefit from community-based care, primary health base care, but there also many for whom this level of care is inadequate. Some suggest that in an extreme sling from instutionalization to deinstutionalizations, these patients paid the cost, becausee they now experience longer illness, more frequent illness and are more vulnerable to things like, violence in a community, and exploitation, because they are simply not in the protected circumstances that they once had. Another issue too, is the rising substance abuse that we see in people who are diagnosed with mental illnesses, which is another way that, that people see them being increased, increasingly exposed to vulnerability. Another troubling aspect of deinstitutionalization is that many people who are diagnosed with mental illness live in our communities facing social isolation, stigma, and discrimination. So this isn't really something that, that originated with deinstitutionalization, but the transfer to the community results in this becoming a part of the daily experience of these people. So, for deinstitutionalization to work, we really needed adequate community services and that's why we'll be talking about community-based mental health care in the next segment.
