Psychiatry Reform Research Articles

Obituary: Professor Ivor Browne, FRCPI FRCPsych MSc (Harv.) DPM.

Professor William Ivory (Ivor) Browne, consultant psychiatrist, who died on 24 January 2024, was a remarkable figure in the history of medicine in Ireland and had substantial influence on psychiatric practice and Irish society. Born in Dublin in 1929, Browne trained in England, Ireland, and the US. He was chief psychiatrist at St Brendan's Hospital, Grangegorman, Dublin from 1965 to 1994 and professor of psychiatry at University College Dublin from 1967 to 1994. Browne pioneered novel and, at times, unorthodox treatments at St Brendan's. Along with Dr Dermot Walsh, he led the dismantling of the old institution and the development of community mental health services during the 1970s and 1980s. He established the Irish Foundation for Human Development (1968-1979) and, in 1983, was appointed chairman of the group of European experts set up by the European Economic Community for reform of Greek psychiatry. After retirement in 1994, Browne practiced psychotherapy and pursued interests in stress management, living system theory, and how the brain processes trauma. For a doctor with senior positions in healthcare and academia, Browne was remarkably iconoclastic, unorthodox, and unafraid. Browne leaves many legacies. Most of all, Browne is strongly associated with the end of the era of the large 'mental hospital' at Grangegorman, a gargantuan task which he and others worked hard to achieve. This is his most profound legacy and, perhaps, the least tangible: the additional liberty enjoyed by thousands of people who avoided institutionalisation as a result of reforms which Browne came to represent.

Historical aspects of ethics in psychiatry : From the end of humanitarianism up to the Human Rights Convention

The establishment of academic psychiatry was completed around 1900. Simultaneously, in view of the societal crisis phenomenon the professional self-concept of the psychiatrist was shifted to aself-image, according to which psychiatry had to place its expertise at the service of the people and the country. This was particularly expressed in World WarI in the brutal dealing with the so-called war neurotics. In association with the so-called death by starvation of ca. 70,000 institution inmates, in the post-war period Karl Bonhoeffer debated a transformation of the term humanitarianism. The worst consequence of the rejection of humanitarian thoughts are the murders of invalids under National Socialism; however, legitimization of such crimes by alluding to collective ethics, as attempted by Karl Brandt, seems to be less than convincing. The reform of psychiatry initiated in the 1960s and the United Nations Convention on the Rights of Persons with Disabilities, which came into force in 2008, have achieved prerequisites for asupportive psychiatry with reduced coercion, whereby many questions also in the legal and social systems must still be clarified.

On the Ideological Function of a Traditional Criticism of Psychiatry in Neoliberalism

Social isolation and discrimination play a major role in the development and maintenance of mental disorders. This could motivate a critical public to demand improved treatment facilities for persons with mental illness. Instead, the media and a critical public tend to repeat a traditional critique of psychiatry, which was articulated before psychiatry reform in the 1970s and which tends to romanticize or neglect mental illness. The replication of this traditional critique of psychiatry today has an ideological function: it reassures a neoliberal public that it is emancipated from traditional authoritarian patterns of dominance, rejects demands for increased funding of mental health treatment facilities, and emphasizes individual autonomy at the price of blaming the victims for homelessness and social impoverishment.

Altha Stewart, M.D., Honored With Pardes Humanitarian Prize

Altha Stewart, M.D., Honored With Pardes Humanitarian Prize

Psychiatry reform in reports of therapeutic residence care providers

Resumo A Reforma Psiquiátrica brasileira criou uma série de dispositivos para substituir o sistema asilar, entre eles o Serviço Residencial Terapêutico (SRT). Com o objetivo de ampliar as reflexões sobre os desafios enfrentados pela proposta reformista, este estudo analisa os discursos construídos pelos cuidadores das residências terapêuticas de Campina Grande (PB), visando detectar estratégias argumentativas favoráveis ou contrárias à Reforma, identificar as identidades que constroem para si próprios, para os demais profissionais da rede de saúde mental e para os usuários do serviço, além de analisar como nomeiam e descrevem o sofrimento psíquico. A pesquisa, de cunho qualitativo, baseou-se na perspectiva teórico-metodológica da psicologia social discursiva. Obtiveram-se 18 depoimentos orais que foram submetidos à análise de discurso. Apesar dos cuidadores se posicionarem a favor da reforma psiquiátrica, apresentam relatos que reforçam a necessidade dos hospitais psiquiátricos, sobretudo, nos momentos de crise dos usuários. Ademais, os profissionais dos hospitais são posicionados, em alguns relatos, como mais capacitados do que os da rede substitutiva. Esses relatos ainda associam o sofrimento psíquico à doença, à periculosidade e à alienação, e caracterizam os usuários como agressivos, perigosos e instáveis. De modo geral, os entrevistados justificam algumas práticas hospitalocêntricas, valorizam o saber médico e reproduzem discursos asilares.

From Editors

The current issue, which we are handing over to you, covers a very wide spectrum of topics close to the heart of psychiatrists and psychologists. Undoubtedly, the article by Henryk Axer is supporting the currently developing model of community treatment in mental disorders. Such small community – based residential programs offer mental health treatment and 24/7 personal care support for adults experiencing severe mental illness. The principles of dealing with residents are of key importance and, according to the author, can gradually improve the independent functioning and coping mechanisms of patients. What are these methods? Take a look at the article, it is definitely worth it, especially at a time when we are debating about the reform of psychiatry in Poland.

Community Mental Health Care in Serbia: Development and Perspectives.

Community mental health care was developed in Serbia in 1982 at the Belgrade Institute of mental health. Treatment was provided through the primary health care system, with each health centre having its own mental health care team. However, in the process of psychiatric reform and deinstitutionalization, dedicated community centres had to be established, in accordance with the National Strategy for the Development of Mental Health Care. The first community-based mental health centre opened in the southern area of Serbia in 2005 and subsequently, other centres were established. The centres are organized independently of psychiatric hospitals and are located in local, self-government units, providing psychosocial treatment and the continuation of mental health care. In relation to the ongoing reform of psychiatry in the country, there are positive and negative issues. There are 41.41 beds per 100,000 of the population in psychiatric hospitals and 18.33 beds per 100,000 of the population in the psychiatric departments of general hospitals. Day hospitals, established throughout the country, provide patients with good quality care. Mental health care professionals are educated to a high standard and integrative, person-centred treatment is applied in most services. However, the level of stigma directed towards those with mental illness is still high and constitutes a barrier to treatment. Well-developed screening and early detection programmes to identify persons requiring mental health care are lacking, as are the records of patients with mental disorders. The future goal is to further reduce the number of beds in psychiatric hospitals, establish new community mental health care services throughout the country and ensure the prevention of mental disorders, as well as mental health promotion.

Community Mental Health Care in Serbia: Development and Perspectives

Community mental health care was developed in Serbia in 1982 at the Belgrade Institute of mental health. Treatment was provided through the primary health care system, with each health centre having its own mental health care team. However, in the process of psychiatric reform and deinstitutionalization, dedicated community centres had to be established, in accordance with the National Strategy for the Development of Mental Health Care. The first community-based mental health centre opened in the southern area of Serbia in 2005 and subsequently, other centres were established. The centres are organized independently of psychiatric hospitals and are located in local, self-government units, providing psychosocial treatment and the continuation of mental health care. In relation to the ongoing reform of psychiatry in the country, there are positive and negative issues. There are 41.41 beds per 100,000 of the population in psychiatric hospitals and 18.33 beds per 100,000 of the population in the psychiatric departments of general hospitals. Day hospitals, established throughout the country, provide patients with good quality care. Mental health care professionals are educated to a high standard and integrative, person-centred treatment is applied in most services. However, the level of stigma directed towards those with mental illness is still high and constitutes a barrier to treatment. Well-developed screening and early detection programmes to identify persons requiring mental health care are lacking, as are the records of patients with mental disorders. The future goal is to further reduce the number of beds in psychiatric hospitals, establish new community mental health care services throughout the country and ensure the prevention of mental disorders, as well as mental health promotion.

CAPS, ateliês e oficinas: artes no mundo, mundos na arte

O artigo propõe-se a analisar de que maneira o encontro da arte com a clínica, sob o viés das oficinas, propostas durante a reforma psiquiátrica, pode constituir-se numa potência, em possibilidades de encontro, na medida em que se afasta de atitudes manicomiais que ainda fazem parte do percurso da saúde mental no Brasil. Pretende evidenciar, por conseguinte, a lógica da clínica ampliada e da redução de danos como bases da atenção psicossocial, tomando como partida o relato da própria experiência institucional enquanto artista plástica de um centro de atenção psicossocial para cuidados relacionados ao uso de álcool e outras drogas. Visibiliza, para este fim, o processo de criação audiovisual colaborativo construído e vivenciado pelos participantes das oficinas de artes, que é atravessado por questões relacionadas à saúde, doença, uso de drogas, redução de danos e liberdade; a produção artística coletiva é conduzida de maneira a ganhar uma dimensão ética e política, assim como o cuidado de si recebe um contorno estético que ultrapassa previsibilidades morais e punitivas.

« La transformation, c’est l’inopiné de l’objet ». Une rencontre avec Vassilis Kapsambelis

ObjectiveThis interview seeks to reflect on the current challenges of training clinicians in a context marked by significant changes in the field of psychiatry. Vassilis Kapsambelis, who has been a teacher for many years (as a theoretician, a clinician, and as an editor) and who has a dual status of psychiatrist and psychoanalyst, gives a lively and authentic accounting of his experience. MethodIn an open conversation with three interlocutors, Vassilis Kapsambelis is asked about his own career, which began in Greece in the late 1970s and continued in France. The analysis of the social and political context of psychiatry over the last forty years is largely evoked. ResultsThis story evokes the personal encounters (colleagues, teachers, and patients) that made a difference, as well as the inspiration of political commitment. Several pivotal periods in the history of contemporary psychiatry are discussed: the reform of psychiatry in the immediate aftermath of the war, the separation of neurology and psychiatry in 1968, the reform of the specialty internship in 1984. DiscussionThe history of psychiatry shows that its course is far from linear. Certain periods can be described as exceptional as they produce profound upheavals of the discipline. This was the case in the years following the Second World War, but this is no longer the case today. It is a “normal” period in the sense that it produces little innovation in clinical work. It is necessary to be able to be inspired by it without living in a sterile nostalgia. ConclusionsEach formation is singular and any subjective transformation is due to the unexpected nature of the object. Clinical training alone cannot engender the commitment and interest that often exist in the would-be clinician, and that can be informed by her or his personal psychoanalysis.

Review of Franz Joseph Gall: Naturalist of the mind, visionary of the brain.

Reviews the book, Franz Joseph Gall: Naturalist of the Mind, Visionary of the Brain by Stanley Finger and Paul Eling (2019). In this book, Finger and Eling describe the rise and fall of phrenology, or organology, the brainchild of Gall. The authors examine the science of mind and brain in the late-18th and early-19th centuries and contextualize his work as the most advanced scientific approach to the study of brain function of his time. Contrary to the way that he is depicted today, Gall is not presented as a charlatan, a quack, or a fraud. He was a physician with a medical degree, a voracious reader, a man familiar with the developments in science and medicine who wanted to develop a science of mankind based on hard facts that others could confirm (p. 122). This book is a reevaluation of Gall's contributions to the science of mind and brain, psychology, and neuroscience, with a focus on the issue of the cerebral localization of function. It also examines Gall's contributions to psychiatry, criminology, and social reform. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Impact of the Zeitgeist and human rights on psychiatric actions

Implementation of the United Nations (UN) Convention on the Rights of Persons with Disabilities (CRPD). The idea of human rights developed during the era of the Enlightenment. This idea has been publicly discussed since the French Revolution of 1789 and its specification has been demanded politically. Important steps in this process were the General Declaration of Human Rights adopted by the UN in 1948 and the CRPD from 2006, which was especially relevant for psychiatric actions. Meanwhile, the idea of human rights has influenced the legislation in many countries and has thus become normatively binding, e. g. in the Basic Law of Germany, in the regulations for patient care and in the professional rules for physicians. To sensitize for reflection on one's own actions and to gain acritical distance from the general overall opinion. Then not only the global validity of the CRPD is frequently violated, as in crisis regions but also in the everyday routine when, for example, the workload prevents psychiatric personnel from taking time for essential conversations with psychiatric patients in order to support their self-determination. These aspects are illustrated and explained with the aid of multifarious examples from the relevant literature and from own experience. Human rights are aregulative idea that provide aframework and direction for psychiatric actions; however, as an idea they compete with other ideas that try to control the trends of the day (the Zeitgeist) that determine daily practice. Not only the suppression of human rights from public consciousness, e. g. with the eugenics in the first third of the previous century but also their absolutization and poor implementation, as in the Italian psychiatry reform of 1978, damage psychiatric patients. Therefore, it appears necessary to sensitize psychiatrists to reflect on the Zeitgeist and its influence on their own actions and to recognize that their own opinions and actions can also influence the Zeitgeist.

O gesto profissional em psiquiatria

Produto de uma pesquisa de doutorado (UFMG/ 2016), o artigo parte de vários desconfortos e questionamentos presentes na prática profissional de um dos autores, de modo a confrontar saberes em diversos campos epistêmicos: normas antecedentes da Psiquiatria, as Clínicas do Trabalho e as práticas em Saúde Mental no contexto da Reforma Psiquiátrica. Tendo como campo de pesquisa um dos serviços substitutivos da Rede de Atenção Psicossocial (RAPS) em Betim/MG, o CAPS III - Centro de Referência em Saúde Mental (CERSAM) Betim Central -, foi analisado um caso, e, nele, um gesto profissional delimitado e discutido. Em síntese, apresentamos um epítome do conceito de gesto profissional em trêsníveis de complexidade.

Teaching ‘small and helpless’ women how to live: Dialectical Behaviour Therapy in Sweden, ca 1995–2005

In 1995, a Swedish pilot study of Dialectical Behaviour Therapy (DBT) was launched to investigate its therapeutic efficacy and cost-effectiveness as treatment for Borderline Personality Disorder (BPD) in suicidal women. In the same year, a sweeping reform of psychiatric care commenced, dramatically reducing the number of beds by the end of the decade. The psychiatry reform was presented as an important factor prompting the need for a community-based treatment for Borderline patients. This article suggests that the introduction of DBT in Sweden, and its relationship to the reform, can only be adequately explained with reference to the wider political shift occurring at the time, whereby the Swedish welfare state and its guiding ethos of egalitarianism were abandoned in favour of a neoliberal ‘choice revolution’. With the new liberalism, hard work and individual responsibility replaced the idea of a Swedish ‘people’s home’, a nationwide community and social support network. This language was reflected in DBT, which sought to teach patients the ‘skills’ necessary ‘to create a life worth living’. In this context, therapy was constituted as a form of ‘work’ that the patient had to undertake to improve. Moreover, DBT rejected the prevailing view of Borderline patients as ‘manipulative’ and ‘aggressive’, suggesting instead that they were ‘helpless’, ‘weak’ and unable to regulate their emotions. This new Borderline persona fit neatly into the new liberal discourse: she could be taught to become a rational and independent person able to cope in a society that valued individual responsibility over social support.

Freud under the Acropolis: The challenging journey of psychoanalysis in 20th-century Greece (1915–1995)

Psychoanalysis was introduced to Greece in 1915 by the progressive educator Manolis Triantafyllidis and was further elaborated by Marie Bonaparte, Freud’s friend and member of the Greek royal family, and her psychoanalytic group in the aftermath of the Second World War. However, the accumulated traumas of the Nazi occupation (1941–1944), the Greek Civil War (1946–1949), the post-Civil-War tension between the Left and the Right, the military junta (1967–1974) and the social and political conditions of post-war Greece led this project and all attempts to establish psychoanalysis in Greece, to failure and dissolution. The restoration of democracy in 1974 and the rapid social changes it brought was a turning point in the history of Greek psychoanalysis: numerous psychoanalysts, who had trained abroad and returned after the fall of the dictatorship, were hired in the newly established Greek National Health Service (NHS), and contributed to the reform of Greek psychiatry by offering the option of psychoanalytic psychotherapy to the non-privileged. This article draws on a range of unexplored primary sources and oral history interview material, in order to provide the first systematic historical account in the English language of the complex relationship between psychoanalysis and Greek society, and the contribution of psychoanalytic psychotherapy to the creation of the Greek welfare state. In so doing, it not only attempts to fill a lacuna in the history of contemporary Greece, but also contributes to the broader historiography of psychotherapy and of Europe.

“Não Converso com Demente”: Intersecções entre Direito e Saúde Mental

Resumo Neste artigo apresenta-se a análise do discurso foucauldiana de enunciados de um dos processos judiciais que compuseram uma dissertação de Mestrado em Psicologia da Universidade Federal de Juiz de Fora (MG). A gênese da pesquisa foi um episódio ocorrido com um usuário de um Centro de Atenção Psicossocial (CAPS), que denunciou sua curadora por maus-tratos e negligência a uma Promotora de Justiça que, mais tarde, recusou-se a recebê-lo afirmando: “Não converso com demente”. A pesquisa, de natureza documental, cujo critério de inclusão foi haver diagnóstico de transtorno mental, foi realizada com três processos judiciais de usuários daquele CAPS. Problematizaram-se as posições de sujeito designadas aos usuários pelo discurso da justiça; as associações e/ou articulações entre o diagnóstico de transtorno mental e outros enunciados e a relação entre curatela, inimputabilidade e cidadania. Pode-se afirmar que o discurso jurídico designa posições de sujeito depreciativas para portadores de transtorno mental, respaldando-se no saber/poder médicos para enunciar verdades acerca dos mesmos. A cidadania é negada por meio da interdição e curatela. Há uma distância entre os códigos Civil e de Processo Civil e as propostas da Reforma Psiquiátrica, especialmente no tocante aos direitos dos portadores de transtorno mental.

Assessment of the priority target group of mental health service networks within a nation-wide reform of adult psychiatry in Belgium.

BackgroundBelgium is currently implementing a nation-wide reform of mental health care delivery based on service networks. These networks are supposed to strengthen the community-based supply of care, reduce the resort to hospitals, and improve the continuity of care. They are also intended to supply comprehensive care to all adult mental health users. It is unclear, however, if one single model of network can target the needs of the whole adult population with mental health problems.MethodsIn 2011, ten networks were commissioned and assessed. Networks included a total of 635 services of different types. Services were asked to select 10 users by systematic sampling and to state whether these users were considered as a priority for care in the network. Sociodemographic, social integration level, diagnoses, and psycho-social functioning variables were also collected.ResultsTwo thousand four hundred ninety users were included, and 1564 were given priority for network care. Priority was higher for men than for women (69.9 % versus 56.2 %), and for non-nationals than for Belgians (72.6 % versus 61.9 %). Users were designated priority when they had poor psycho-social functioning (HoNOS > 17, OR = 3.15, p < 0.001), personality disorder or schizophrenia (OR = 1.54, p < 0.001), and a medium level of social integration (SIX = [2,3], OR = 1.57, p < 0.001). Less socially integrated patients (SIX < 1, OR = 0.53, p < 0.001) and users of community and social services were less likely to be selected.ConclusionAlthough the reform was intended for the whole population of adults with mental health problems, the users selected have a profile of severe mentally-ill users with social deprivation and poor social functioning. Policy may have been over-ambitious trying to address the whole population with one single type of service network. The actual selection process of users makes it less likely that the reform will achieve all its objectives.

Postsocialism, the psy-ences and mental health.

Over the past decades, the formerly socialist countries of East Central Europe and Eurasia have experienced a range of transformations which bear directly upon the domains of mental health, psychiatry, and psychology. In particular, the disciplines and professions concerned with the human mind, brain, and behavior ("the psy-ences") were strongly affected by sociopolitical changes spanning the state-socialist and postsocialist periods. These disciplines' relationship to the state, their modes of knowledge production, and the epistemic order and subjectivities they contributed to have all undergone dramatic ruptures. In this essay, we trace the literature on these issues across three thematic domains: (a) history and memory; (b) the reform of psychiatry in an era of global mental health; and (c) therapy and self-fashioning. We argue for a closer articulation between the social science and historical literature on socialism and its "posts" and the literature among anthropologists, sociologists, and historians on the sciences of the mind and brain, and we suggest that each of these literatures helps to critically open up and enrich the other.

Attentes et promesses du risque de psychose

ObjectiveThe category of “at-risk” mental states was created during the second half of the 1990s to characterize clinical presentations that were liable to evolve into psychosis within months. At-risk mental states are at the center of a new psychiatry among young adults. This article examines the expectations and promises of this form of psychiatry. MethodsThis article uses an approach based on the sociology of knowledge, highlighting the interests, the institutional contexts and the practices that contribute to shaping psychiatric knowledge and categories, as well as the debates generated by this knowledge and these categories. ResultsOver the last twenty years, debates on at-risk mental states have resulted in a shift in the way clinicians understand this category. The difficulty in stabilizing the risk of transition to psychosis among patients concerned has led proponents of this category to argue for a new interpretation: without being necessarily the sign of a transition towards psychosis, at-risk mental states could point to a pathological outcome that remains open as to its development, and certain as to its endpoint. Two different approaches towards these issues have emerged within the psychiatric community: the first seeks to refine the at-risk category to make it a truly predictive category, the second to use it as the starting-point for a new public health strategy aiming to improve mental health among young adults. DiscussionAt-risk mental states create a paradoxical clinical area of expectation, characterized by the indeterminacy of its perspectives and promises. This indeterminacy could explain its success among a wide array of people with diverse interests from clinical, research and public policy circles. ConclusionA better understanding of the dynamics of innovation and reform in psychiatry could be gained from paying more attention to the social underpinnings of psychiatric promise.

Post-Psychiatry: A New Orthodoxy?

This article examines the character and purported aims of post-psychiatry, a new endeavor aimed at linking psychiatry with elements of post-modernity. While not strictly a “movement” in psychiatry, post-psychiatry represents a growing impatience, in some quarters, to conventional approaches to psychiatric practice. It has the potential to challenge established assumptions about what is necessary for the management and care of psychiatric patients and to articulate concerns about the use of coercion in psychiatric practice. In particular, post-psychiatry is responsive to current threats to the perceived hegemony of psychiatry, notably in the increasing acceptance of non-medical approaches to psychological distress and in the internal professional conflicts concerning the diagnosis, treatments for and the social purpose of psychiatry. The article outlines various reflections on the reform of psychiatry and considers some features of the impact of post-modern theory on psychiatry.