Era Of Deinstitutionalization Research Articles

Gilles Deleuze's societies of control: Implications for mental health nursing and coercive community care.

Since the era of deinstitutionalisation, many clinical approaches have emerged to enable the care and treatment of people suffering from mental illness. In recent years, the use of coercive approaches in the community (e.g., outpatient commitment or community treatment orders) has also increased internationally. Although nurses' role regarding these coercive approaches is central and significant, few empirical and theoretical writings have tackled this controversial nursing practice. The purpose of this paper is to analyse coercive nursing care through the lens of French philosopher Gilles Deleuze's concept of 'societies of control'. Taking up Michel Foucault's work on disciplinary power, Deleuze explores how the move from the striated spaces of closed institutions to the smooth spaces of societies of control took place since the middle of the 20th century. According to Deleuze, the overall objective of 'societies of control' is no longer simply to govern deviant behaviour in closed environments (e.g., psychiatric hospitals and prisons) but to ensure a regime of unrelentless surveillance in the open spaces of our communities.

14Disability Studies

Abstract This chapter reviews recent publications in the field of disability studies on disability and criminal justice systems, particularly through the processes of institutionalization and incarceration. The main texts that serve as the corpus for this review define disability broadly, though devote analysis to historical constructions of intellectual/developmental disability and psychosocial disorders, labels that are critically evaluated in each text as well as in this review. By concentrating on institutionalization and incarceration, these texts are specifically focused on how ‘disability’ is entangled in the criminal justice systems of Anglo legal structures (USA, Canada, England, Scotland, Wales, Northern Ireland, the Republic of Ireland, New Zealand/Aotearoa, Australia) that developed out of English-speaking imperial forces. Specifically, these texts take issue with the idea that the process of deinstitutionalization, the movement of disabled individuals from enclosed facilities to inclusive community settings, was successful in liberating disabled individuals, specifically disabled black, Indigenous populations. This chapter proceeds in four sections. First, we focus on the contemporary definitions of institutionalization and incarceration across the different legal systems traversed by each author. Second, we consider the organizing tension of neoliberal capitalism as a framework through which to analyze and critique continued forms of institutionalization and incarceration. Third, we observe the need to center disabled black, Indigenous experiences of incarceration and institutionalization under the auspices of ‘inclusion’ in the supposed era of deinstitutionalization. Lastly, we move through the alternatives to the forms of institutionalization and incarceration assessed in these texts and offer directions for further critical thought.

Suicide intervention training with law enforcement officers.

Law Enforcement Officers' (LEO) interactions with people facing mental health crises have risen exponentially since the era of deinstitutionalization. On average, about 10% of the individuals law enforcement interacts with daily have mental health challenges. Several factors influence the outcome of these interactions, not least of which is an officer's role as a gatekeeper as well as their training related to people with mental health challenges. We hypothesized that participating in the online QPR Training for Law Enforcement Officers would be associated with improved knowledge about suicide, attitudes to suicide and suicide intervention, and self-efficacy. Additionally, we hypothesized that these outcomes would be associated with greater use of intervention skills when encountering individuals at risk for suicide in the community. Results of our longitudinal analysis find that most of the participating officers reported some prior training and yet demonstrated statistically significant improvements in knowledge and attitudes after controlling for previous training. No significant changes were observed in LEO's use of intervention skills following training. We conclude by suggesting that there is substantial need for increased training; and offering possible conceptual and empirical explanations for the observed results.

Case Study Supporting the Return of Long Term Psychiatric Institutions for Patients with Severe Persistent Mental Illness

There has been a surge of greater than 30% in the rate of inpatient psychiatric readmissions amongst patients with severe mental illness following the era of deinstitutionalization and co-morbid medical illness has been found to be a consistent factor amongst this subset of patients. Hospital psychiatrists often see these patients revolve in and out of the hospital, a phenomena known to negatively impact their quality of life. Having a highly structured 24-hour long term psychiatric institutions is a much needed resource for patients with severe mental illness who are unable to take care of self.

'Heading up a blind alley'? Scottish psychiatric hospitals in the era of deinstitutionalization.

This article examines Scottish provision of psychiatric care in the 1960s and 1970s. It demonstrates that institutional services did not rapidly disappear across the UK following the Ministry of Health's decision to shut down psychiatric hospitals in 1961, and highlights Scotland's distinctive trajectory. Furthermore, it contends that psychiatric hospitals developed new approaches to assist patients in this era, thereby contributing towards the transformation of post-war psychiatric practice. Connecting a discussion of policy with an analysis of provision, it examines the Department of Health for Scotland's cautious response to the Ministry's embrace of deinstitutionalization, before analysing Glasgow's psychiatric provision in the 1970s. At this point the city boasted virtually no community-based services, and relied heavily on its under-resourced and overburdened hospitals. Closer analysis dispels any impression of stagnation, revealing how ideologies of deinstitutionalization transformed institutional care.

Dorothea dix: A proponent of humane treatment of mentally ill

The work of early pioneers like Dorothea Dix was instrumental in the establishment of institutions dedicated especially for the care of the mentally ill. Originally from the United States, she became acquainted with the idea of humane treatment of the mentally ill during her visit to England. After her return to the United States, she conducted a statewide investigation of care for the insane poor in Massachusetts and began to extensively lobby for reforms and establishment of more state-funded institutions for the care of mentally ill. Her efforts led to setting up of several mental health institutions, which became the cornerstone of care of psychiatrically ill, and for training of mental health care providers. Though subsequently, the hegemony of the institutions was challenged, and the era of deinstitutionalization was ushered in, the work of Dorothea Dix is important as it vouched for humane care of patients with mental illnesses.

Rate of Family Violence Among Patients With Schizophrenia in Japan.

Family violence is a serious concern in the era of deinstitutionalization in Japan. Consequently, we aimed to clarify the rate of family violence among patients with schizophrenia, and differences by sex and relationship to the patient. We asked households belonging to a family group association to complete a self-administered mail survey. Of 350 households that responded, data for 302 were analyzed. The rate of violence toward any family member was 60.9% over the lifetime and 27.2% in the past year. Order of lifetime rates for family members from highest to lowest was 51.0% for mothers, 47.0% for fathers, 30.7% for younger sisters, 23.8% for spouses, 19.5% for younger brothers, 18.2% for older sisters, 17.1% for older brothers, and none for children. Younger sisters were more likely to be victims compared to other siblings. Fathers and older brothers were likely to be victims when patients were male.

Dromokaition Psychiatric Hospital of Athens: from its establishment in 1887 to the era of deinstitutionalization.

Dromokaition Psychiatric Hospital opened its doors in 1887, following the donation made by Zorzis Dromokaitis from the island of Chios. Private donations and all forms of charities had contributed to a large extent in the establishment of hospitals across Greece, during the late 19th and the early 20th century. Dromokaition was one of them but it was also unique, as it was the first psychiatric hospital in Athens, admitting patients from every part of the country. This paper aimed at highlighting the long service of the institution through the different historical periods the country went through. We present the chronicle of its foundation, the development of its inner structure, and the medical and organizational influences which it received, along the way. The therapeutic methods used during the first decades of its operation reflected the corresponding European standards of the time. As a model institution from its foundation, it followed closely the prevailing European guidelines, throughout its historical path, either as an independent institution or as an integrated one within the National Health Service.

Using autoethnography to reclaim the ‘place of healing’ in mental health care

Geographies of mental health in the era of deinstitutionalisation have examined a range of places, policy processes and people's experiences associated with community care. However, such assessments have tended, given their community focus, to necessarily be silent on the character of inpatient spaces of care. There is silence too on the potential of such spaces to assist in the healing journey. While there have been a few investigations of hospital design, there has been little consideration of users' experiences of hospital spaces as critical sites and spaces of transition on the illness journey. In this paper, we critically reflect on a project that seeks, two decades after the closure of the last major institution in New Zealand, to investigate the acute care environment with an emphasis on its capacity for healing. The vehicle facilitating this investigation is a novel approach to understanding the inpatient journey: autoethnography. This methodology allows the first author (JL) to critically reflect on her multiple roles as compassionate observer, service-user and mental health professional, and developing transdisciplinary insights that, in conversation with the other authors' geographical (RK) and psychological (PA) vantage points, assist in the reconsideration of the place of the inpatient unit as a place of healing. The paper reveals how voice, experience and theory become mutually entwined concerns in an investigation which potentially stretches the therapeutic landscape idea through critical attention to the redemptive qualities of place by means of attentiveness to both the world within and the world without.

Five-year mortality of Finnish schizophrenia patients in the era of deinstitutionalization

Excess mortality among people with schizophrenia due to natural and unnatural causes, especially due to suicides, is a well-known fact. It has been suggested that deinstitutionalization increases suicide mortality but there are also contradictory results. We studied the changes in mortality and causes of death among schizophrenia sufferers during and after the years of deinstitutionalization process in Finland. The sample, identified from the Finnish hospital discharge register (FHDR), consisted of patients aged 15-65 and hospitalized for the first time due to schizophrenia. We focused on the 5-year follow-up from inclusion years 1980-1998 (N=23,959). Changes in 5-year follow-up mortality during the study period were explored for both genders and for different causes of death separately using multivariate logistic regression analyses. During the study period 1,926 deaths occurred. Suicide was the major cause of death in both genders. A significant reduction in overall 5-year mortality was observed among persons hospitalized in 1995-1998 when compared to people hospitalized 1980-1984. In males a significant reduction was seen in all mortality (P=0.025) due to suicides (P=0.007) but not in the case of natural deaths. In females no significant changes in mortality were found. Our study confirms a reduction in suicide mortality of male schizophrenia sufferers after the deinstitutionalization process. However the overall mortality is still very high and the attention needs to be focused on the general well-being of schizophrenia patients.

Paternalism in mental health: time for rehabilitation?

Mental health legislation has received enormous attention internationally in the era of deinstitutionalization, particularly as societies become more risk averse. The response has been framed within a libertarian tradition and the language is almost exclusively about autonomy and partnership. Apart from risk, patient autonomy has gone from being one of the principles in the discourse surrounding mental health legislation to being the principle one. Paternalism and beneficence are discarded as discredited. Practice, however, is still recognisably paternalistic in most developed countries. This disjunction between the public language and common practice leads to sometimes tortured and unconvincing definitions (to permit current practice) and unhelpful confusion in the public mind about what psychiatry is. Contrary to the widespread belief within mental health that everyone else has abandoned paternalism there are cogent and respectable critiques of autonomy as a dominant ethical principle. These critiques encourage a less damning view of paternalism seeking to place it alongside other ethical goals in society. These challenges come from within economics, the law, political philosophy and, perhaps most surprisingly, from some feminist authors. These critiques will be briefly outlined with the modest ambition of encouraging debate in this area. While patient autonomy is important it does not preclude the legitimate consideration of restriction of liberty in a patient's best interests. A debate which reflects more accurately what we do (rather than think we ought to do) may be more helpful in informing policy and legislation.

Conversation with William L. White

Conversation with William L. White

In sight, in mind: mental health policy in the era of deinstitutionalisation

This paper outlines the key goals of Australia’s National Mental Health Strategy in attempting to persuade state governments to pursue the progressive deinstitutionalisation of Australia’s stand alone public psychiatric hospitals and the mainstreaming of inpatient psychiatric care in wards of general hospitals. It utilises Goffman’s (1961) critique of asylums and the comprehensive audit of Victoria’s public psychiatric services in 1992 to illustrate some important deficiencies in the old asylum system of mental health care. The paper argues that, though the process of deinstitutionalisation in Australia is incomplete and there are many problems, sufferers from mental illnesses are now in a very real sense ‘in sight’ and ‘in mind’. The paper concludes with proposals for sociological research in the mental health field.

Schizophrenic patients in different treatment settings during the era of deinstitutionalization: three-year follow-up of three discharge cohorts in Finland.

We investigated differences in psychosocial and clinical characteristics, as well as the use of services, of schizophrenic patients in different treatment settings three years after their discharge from a psychiatric hospital. Furthermore, we examined secular changes in these phenomena during the era of rapid deinstitutionalization in Finland. Three nationally representative samples comprised 3257 schizophrenic patients who had been discharged in 1986, 1990 and 1994. The patients were interviewed three years after discharge by each district's psychiatric professionals using a structured interview schedule specifically designed for the purposes of the present study. Psychosocial functioning was assessed on the Global Assessment Scale and on a modified version of the Medical Research Council Practices Profile. In the 1990s, more patients with a poor clinical and psychosocial state were transferred from hospital to alternative outpatient facilities, such as sheltered workshops or supported residences. In successive cohorts, the proportion of patients who had dropped out of treatment decreased and the psychiatric and somatic state of the drop-outs improved. In general, the psychiatric treatment system has worked well for most deinstitutionalized patients. In the future, however, it is important that the quality of care and adequate resources in the alternative outpatient facilities are ensured.

Preserving the Institutional Past and Histories of Psychiatry: Writing about Tokanui Hospital, New Zealand, 1950s-1990s

role of institutional histories in evaluating psychiatry's past. Located near the small town of Te Awamutu in the North Island, Tokanui opened in 1912 and housed people with intellectual disability, those with acute psychiatric disability and those with neurological impairment.1 By the 1950s, Tokanui was overcrowded, housing more than 1000 patients. For many members of its community, the institution was a happy place. Tokanui's fiftieth Jubilee commemoration took place in 1962, and, at that point, a brief history was prepared to mark the half century of a place that had developed and changed alongside psychiatric practices in New Zealand. Tokanui also celebrated with a Jubilee ball, the proceeds of which helped to fund a swimming pool, opened later in 1968. Such practices and performances at moments of historic significance for institutions like Tokanui show that 'history' itself was valued by the institutional community. This article suggests that institutional histories have become even more important for places like Tokanui since the era of deinstitutionalisation or institutional closures. In New Zealand, this era was officially underway by the 1980s, but was arguably a process that began much earlier, as historians have suggested. In order to explore the value of an institutional history of Tokanui, the article provides some background to Tokanui's history and examines the experiences of the institution from the 1950s, and in the following decades until its proposed closure in the 1990s. It uses archival materials, official government records and histories of other New Zealand institutions. It also refers to some oral histories of members of Tokanui's community that were recorded in the 1990s to explore the problem of institutional memory and histories of psychiatry following the era of deinstitutionalisation. It argues that many histories of twentieth-century psychiatric institutions, produced during and after the era of deinstitutionalisation,

Inpatient treatment of mood disorders in the era of de-institutionalisation, depression awareness campaigns and development of new antidepressants

Objective: To analyse changes in inpatient treatment for mood disorders during the period of de-institutionalisation, de-centralisation of service planning, economic recession, attempts to increase depression awareness and increasing biological treatment possibilities. A special interest is paid to whether de-institutionalisation at specialist level psychiatric care results in transfer of inpatient care into non-specialised institutions. Method: A register study of all inpatient treatment due to psychiatric disorders from four health care districts in Northern Finland, with a population of more than 600,000. Treatment undertaken by psychiatric hospitals and wards, primary care wards and medical and surgical wards in general hospitals are distinguished. Results: Inpatient treatment for mood disorders increased vastly in all kinds of health care institutions. The increase was due to growing inpatient treatment of depression. Limitations: The National Discharge Register does not include treatment episodes in private nursing homes or details about the contents of the treatment. Conclusion: Even during explicit active de-institutionalisation, other policies may have a greater impact on hospital use, resulting in unexpected changes in patient populations and service utilisation. In Finland, de-institutionalisation failed concerning mood disorders. The depression awareness policies during the 1990s increased inpatient use of depression across institutions.

Psychiatric bed reductions and mortality among persons with mental disorders.

Psychiatric bed reductions and mortality among persons with mental disorders.

Mental disorder and violence: results of epidemiological studies in the era of de-institutionalization

Mental disorder and violence: results of epidemiological studies in the era of de-institutionalization

The biopsychosocial legacy of deinstitutionalization.

The growth of homelessness as a problem affecting the long-term mentally ill patient population attests to the fact that many individuals fail to be served by mental health agencies in this era of deinstitutionalization (1). Even those who are on agency rolls often receive far less than adequate and sensitive care (2). Thus it is hardly surprising that I feel some hesitation in writing about a “legacy” of deinstitutionalization. Yet it would be misleading to suggest that deinstitutionalization has been an unqualified failure. I have written and spoken frequently about the serious problems that have accompanied that movement (3,4), and I fully intend to continue to do so. However, I must also acknowledge the positive legacy ofthis policy. The legacy consists of our heightened awareness of the humanity and the needs of mentally ill individuals. And although this awareness may not appear to be a very substantial gift in view of all the suffering and inequities that have accompanied the movement, I believe it to be quite a remarkable legacy.

Service Planning for Chronic Mental Patients: Some Principles

Services for chronic mental patients in this era of deinstitutionalization present a major challenge to clinicians and planners alike. The complexity of these patients' clinical and other programmatic needs requires that an array of viable comprehensive services be made available to them. Following certain established principles of service planning will help facilitate patients' longitudinal, psychological, financial, and geographical access to care.