From Aftermath Psychiatry to Lattermath Psychiatry, or from Deinstitutionalisation to Community-Centric Mental Health Services, and now to Mental Health Care Ecosystems: Beyond Symbols, Stereotypes, and Stigma of Home Visiting and Assertive Community Teams

Abstract

From Aftermath Psychiatry to Lattermath Psychiatry, or from Deinstitutionalisation to Community-Centric Mental Health Services, and now to Mental Health Care Ecosystems: Beyond Symbols, Stereotypes, and Stigma of Home Visiting and Assertive Community Teams1 Alan Rosen (bio) What does the evolution of architecture have to do with the deinstitutionalisation of psychiatry and the evolution of community mental health services? And how do these trajectories relate to the quest to destigmatise mental health services so they will be more approachable earlier by individuals and families in need of them? The arguments advanced by Terry Smith in The Architecture of Aftermath suggests that a) worldwide, there is not only an economy but an icon-omy, and b) global architecture has been reeling from the destruction of global icons such as the World Trade Centre in New York on 11 September 2001.2 There should be a growing discomfort among entrepreneurs, developers, and architects that their construction of iconic buildings to promote national or global perpetual brands, symbols, or empires has been transformed in the public mind into building impermanent ‘soft targets’, vulnerable to terrorism. Smith argues that architecture has lost its way from its roots in creating homes and communities for all.3 Similarly, psychiatry may also have lost its way in the eyes of the public, the face of the market, and from the loss of its iconic massive institutions. Meanwhile, it had been long in retreat from engaging with whole communities to improve their wellbeing and mental health, and by neglecting to promote full membership of the community and full human rights while controlling the lives of people contending with severe mental disabilities. Instead, psychiatry has continued to build clinical edifices, fortress hospitals, and academic empires, with overreliance on medications, long-acting injections, ECT (electro-convulsive therapy), indefinite incarcerations, involuntary control, (arguably) captive fodder for research of variable worth, alienation, abuse, and neglect. These have become its dominant, stigmatising, and ultimately dysfunctional public symbols and icons. More recently, Terry Smith has also invoked a related concept: the ‘lattermath’, a late fifteenth-century term for new shoots of grass growing after [End Page 161] a harvest, or mowing, so we are not perpetually entrapped in the leftovers of aftermath, as it can lead to new life, new growth and new hope.4 That this may help us to make the case that a renewal of hope for psychiatry, especially via shifting its balance towards a familiar home context or a community centre of gravity, is imaginable.5 I have described the progression from deinstitutionalisation to ‘aftermath’ psychiatry consisting of clinical edifices, fortress hospitals, and academic empires with only occasional outreach, to a more hopeful ‘lattermath’ of new shoots of growth for a more hopeful, community-centric rights-based psychiatry with ‘in-reach’ to hospitals if, and when, necessary. Our mental health professions do not have to be left perpetually trapped in the rubble and debris of our old practices and approaches. Instead, it can be demonstrated that, if examined closely, there is ‘lattermath’ growth occurring in psychiatry leading to new life, new growth, and new hope for the profession. The public and wider community has usually welcomed most phases of development of community psychiatry, from pastoral home visits to crisis intervention and service delivery systems of evidence-based complex integrated community mental health care like assertive community treatment (see Table 1). These approaches, if properly applied, can confer much more respect and may diminish the power differential considerably. Communities have been disappointed when they have been withdrawn due to backlash from more institutionalised professionals or politicians.6 Can psychiatry revive itself through a new growth of practice innovation and evidence-based community mental health services for all, situated in the complexities and contexts of their own lives, and ‘on their own turf and terms’, often in their own homes, on their own streets? Can community psychiatry encompass both the necessary technical interventions and service delivery systems, while also facilitating human rights, humane relationships, more benign meanings, and purposes fostering healing, recovery, and communal wellbeing? If we do not learn better to integrate these needs, our future in psychiatry will continue to be like trying to tie together architectural gestures and...