Deinstitutionalisation

Question 1

What characterises deinstitutionalisation?

Answer 1

> 1954 - 2012: steady, massive decline of hospital bed numbers
-> hospital closures

> 1954: 60 years of deinstitutionalisation began

• Renewed therapeutic optimism
• Newly-trained psychiatrists following WWII

> Peak bed numbers were reached at different times from the 1940s onwards

> 1950s - 1960s:
Rise of the Welfare State -> Social Security benefits
-> support people who couldn’t support themselves out of asylums
The District General Hospital movement “Psychiatry in White Coats”
-> new effective treatments
- Chlorpromazine: Psychosis
- Iproniazid and Imipramine: Depression

> 1970s: All advanced countries began the process of deinstitutionalisation (except Japan where bed number increased)
- England, Australia and New Zealand in the forefront

> 1978 “Italian Experience” : radical movement for closing all psychiatric institutions

Question 2

What was the first sign anticipating the beginning of deinstitutionalisation, before 1954?

Answer 2

Mental Aftercare Association founded in 1879 by Colney Hatch Asylum.

Question 3

What is deinstitutionalisation?

What are its 2 focuses?

Answer 3

A process of replacing long-stay psychiatric hospitals by less isolated community mental health services, for those diagnosed with mental disorders or developmental disability.

> Reducing the population size of mental institutions
- releasing patients, shorter stays, reducing admission/readmission rates

> Reforming mental hospitals’ institutional processes
- reduce/eliminate reinforcement of dependancy, hopelessness, learned helplessness… maladaptive behaviours

Question 4

What are the steps of deinstitutionalisation?

Answer 4

1. Running down the traditional mental hostpitals by improving throughput
2. Developing community-based services
3. Improving practice within the psychiatric hospitals

Question 5

What is the perspective of E. Fuller Torrey in ‘Out of the shadows: Confronting America’s mental illness crisis’ (1997)?
What is his critic of deinstitutionalisation?

Answer 5

He writes from the perspective in the USA:
> A different social healthcare system where deinstitutionalisation started at the same time than in the UK, BUT proceeded much faster and further

> Deinstitutionalisation has resulted in people getting no care at all

• “Deinstitutionalisation further exacerbated the situation because, once the psychiatric beds had been closed, they were not available for people who later became mentally ill […]. Consequently, approximatively 2.2 million severely mentally ill people do not receive any psychiatric treatment
• “For a substantial minority, however, deinstitutionalisation has been a psychiatric Titanic. […] The “least restrictive setting” frequently turns out to be a cardboard box, a jail cell, or a terror-filled plagued by both real and imaginary enemies.”

Question 6

What does Marshall (1998) call transinstitutionalisation?

What is his critic of deinstitutionalisation?

Answer 6

> “A process whereby individuals, supposedly deinstitutionalised as a result of community care policies, in practice end up in different institutions, rather than their own homes.”
-> an allied phenomena to deinstitutionalisation

> Deinstitutionalisation is a fiction
- what changed is the location of people’s institutionalisation

Question 7

What is Andrew Scull’s critic of deinstitutionalisation (1977)?

Answer 7

‘Decarceration’ (1977, 1984):
> Motivation to close mental hospitals is to:
- save money
- shift costs
- encourage private sector (for profit providers)

“Evidence of benefits to [deinstitutionalised] psychiatric patients, especially those hospitalised over long periods, is not to be found anywhere in the psychiatric literature”

Question 8

What evidence proved that Andrew Scull’s critic of deinstitutionalisation is wrong?

Answer 8

The Team for the Assessment of Psychiatric Services (TAPS) and other studies showed that:
- people improve in good quality community settings and deinstitutionalised hospital setting replacements

Question 9

What is the optimistic view on deinstitutionalisation?

Answer 9

People are now living successful lives out of hospital following a diagnosis of severe mental illness and receiving appropriate treatment and community support.

Question 10

What did we see in the US and in the UK during the deinstitutionalisation period?

Answer 10

1. Mental hospitals got smaller
2. Expansion of psychiatric units in general hospitals
3. Development of free standing new small psychiatric hospitals
4. Large mental hospitals closed

Question 11

What can be criticised about the NHS bed data (KH03) on the deinstitutionalisation period?

Answer 11

> It ignores NHS-funded private sector beds
Steady reduction in bed numbers since 1954 in the face of a rising population

(purchased private sector beds are now included in the total bed numbers)

Question 12

What do international trends in inpatient provision show between the 1970s and now?

Answer 12

All European countries have now less beds than they had in the 1970s.

Question 13

What does the Project Atlas by WHO (2005) show about the European data on trends in the numbers of psychiatric beds in Western Europe?

Answer 13

> The UK deinstitutionalised more aggressively than most other high-income countries

• six-fold reduction (6 times less) from 1954 to 2004
• nine-fold reduction (9 times less) from 1954 to 2015

> Mean bed numbers in high-income countries in 2004: 75 / 100,000
UK in 2004: 58 / 100,000
- now 42 / 100,000
-> low in international comparison

Question 14

What are the drivers of deinstitutionalisation?

Answer 14

1. Psychotropic medication revolution
2. Changes in professional attitudes post-WWII
3. The “open-door” movement in mental hospitals
4. The introduction of occupational therapy and work rehabilitation in the mental hospitals in the 1950s
5. The rise of the “Welfare State” and change of access to welfare benefits
6. The attractive concept of “community care”
7. Evolution of mental health law
8. Ideas about institutions
9. Cost

Question 15

What does Russel Barton (1959) call “Institutional neurosis”?

Answer 15

A ‘syndrome’ of apathy, lack of initiative, loss of interest and submissiveness.

Question 16

What does Erving Goffman present in ‘Asylums’ (1961)?

Answer 16

A sociological critique of the asylum and other “total institutions”.

Question 17

What does Wing and Brown present in ‘Institutionalism And Schizophrenia’ (1970)?

Answer 17

Empirical study:
> The effect of institutional practices on psychiatric disability
> “Negative symptoms” of schizophrenia
- reactive to the social environment in the 3 hospitals they studied

Question 18

What does the American neurologist S Weir Mitchell (1894) think of asylums?

Answer 18

“Upon my word, I think asylum life is deadly to the insane”.

Question 19

Is there an example of politics as a driver for deinstitutionalisation?

Answer 19

Enoch Powell (then Minister of Health),
Speech to the Conservative Part Conference (1961):
“Do not for a moment underestimate their powers of resistance to our assault” (his decision to close mental hospitals).

Question 20

How was the hospital closure process in the USA?

Answer 20

Early and rapid deinstitutionalisation aided by financial and legal drivers.
- e.g. mass action suits instructed mental hospitals to discharge patients en masse

Question 21

What was one of the first hospitals to close in England?

What was the state of hospital closure by 2000?

Answer 21

> Banstead Hospital closure in 1986

> By 2000, the majority of mental hospitals had closed

Question 22

What were the common factors in hospital scandals, described in J.P. Martin’s ‘Hospitals in trouble’ (1984)?

Answer 22

Hospital scandals concerning the mentally ill, the elderly and people with learning disabilities:
> Poor top management
> Poor nursing leadership
> Poor medical leadership
> Lack of multidisciplinary working
> Distorted unit culture
> Lack of clarity over task of unit (relevant to long-stay institutions)
> Isolation

Question 23

What were the financial issues of deinstitutionalisation?

Answer 23

1. Significant capital value to be released on closure
2. Changes in Social Security-funded community care services -> cost-shifting from one budget to another
3. Fixed costs irrespective of bed numbers

Question 24

What were the outcomes of deinstitutionalisation?

Answer 24

> The English hospital closure programme

• began in 1986
• use of some sites for general hospitals and part-use of sites for inpatient units
• development of small “secure” hospitals within the NHS and the private sector

> 116 of the 130 traditional Mental Hospitals in England and Wales had closed by 2001

Question 25

With the example of the Cane Hill Hospital closure, what were the goals set by professionals (including this class lecturer Dr Frank Holloway)?

Answer 25

> Comprehensive local community and inpatient mental health services, in line with mental health policy in England
Improve the lives of current inpatients
Develop contemporary community mental health services

Question 26

What happened to Patients who were discharged from Friern Barnet?
What about the patients with challenging behaviours?

Answer 26

> They were moved, into traditional living settings

• happier
• improved social functionning
• developed larger social networks
• no homeless and little offending behaviour

> Patients with challenging behaviours were moved into specialist ‘hospital facilities’ much more homely

• improvement in social functioning
• improvement in the level of challenging behaviours
• 40% moved into non-hospital settings

Question 27

What is the post-deinstitutionalisation situation in the UK, the actual complexities?

Answer 27

1. Closing the large mental hospitals didn’t abolish severe mental illness in the UK
2. The hospital closure programme destabilised acute inpatient services in deprived urban areas in the early 1990s
3. In the UK inpatient beds have been replaced by care in high-support setting - ‘virtual asylums’
4. Even with well-developed community services, acute inpatient beds are required
5. Some people have continued to need longer-term inpatient care in forensic and rehabilitation inpatient settings