Reinstitutionalisation in mental health care
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7382.175 (Published 25 January 2003) Cite this as: BMJ 2003;326:175
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
13/02/03
Editor,
I think it is high time that the terms "de-institutionalisation" (DI)
and "re-institutionalisation" (RI) were discarded. DI is just the transfer
of a patient from what is perceived to be a less appropriate institution
to one that is perceived to be more appropriate. RI is the reverse. It is
unfortunate that "institution" and "dependence" have virtually become four
letter words.
We are all institutionalised. Institutions are instruments of social
regulation. They are the skeleton of society, without which it would
collapse. We all depend on the framework of interlocking institutions for
both the regulation and the facilitation of our lives. The question for
each individual is - what is the appropriate institution for this person.
If we become physically or mentally disabled we become more dependant and
we, with our carers need to find the optimum level of support, from which
institution.
I am also surprised by the authors' anxiety over social control of
patients. We are all subject to social control but accept it so readily
that we feel no constraint from law and custom. Custom can be more
oppressive than law - I can usually get away with exceeding the speed
limit but if I came to work in a bathing costume my job would soon be at
risk.
I would also query the author's doubts about he effectiveness of secure
units. At the very least they contain patients who cannot be contained in
open units, whose effectiveness is also problematic.
The way to reduce the stigma arising from the management of the mentally
ill is to accept that we are all in the same boat.
1. Priebe S, Turner T Reinstitutionalisation in mental health care,
BMJ:2003:326:176-7.
Yours truly,
G O DUBOURG
23 misterton crescent
Ravenshead
Notts NG15 9AX
(I emailed this to you on 13.2.03 and it was treated as paper mail. Why?
Competing interests:
None declared
Competing interests: No competing interests
Priebe and Turner’s editorial is a welcome addition to the debate
about long-term mental health care in the 21st century. However, we
believe that issues of control and duress are not identical to
institutionalisation and “re-institutionalisation”, though there is
considerable over lap.
The notion of reinstitutionalisation implies that the process of
deinstitutionalisation was completed. In fact, populations have moved
between large mental hospitals and other institutions continuously ever
since the Victorian asylums were built. We have suggested that many people
now live within a “virtual asylum” (1) which is largely invisible and
ineffectively managed by those who commission its services.
Institutionalisation is not primarily determined by processes of
duress, as suggested by the authors. The essential feature of a “total
institution” is that its residents are not free to pass through its doors
unimpeded. The loss of this freedom brings other processes into play which
lead to the adverse consequence of institutionalisation. No matter how
intrusive community services may be, they cannot inflict the damage caused
by losing control over where you go and who you associate with. The size
of the building is less relevant than control over fundamental aspects of
daily living. The features of institutionalisation described by Goffman(2)
have not been reported to exist in community services working without
physical boundaries.
This is not to say that the potential for control, duress and
coercion within community services is negligible. On the contrary, central
policy based on the indiscriminate exercise of power over the mentally ill
living in the community is a major ethical and practical worry. It opens
up possibilities of new types of damaging intervention. However, these
issues should be debated on their own merits. At a time when significant
numbers of people are experiencing long stays within the walls of new
physical institutions it would be wise to remember the lessons of history,
such as why asylums got such a bad name in the first place. Institutions
have walls.
(1) Poole R, Ryan T, & Pearsall A. The NHS, the private sector
and the virtual asylum. BMJ 2002 ; 325; 349-50.
(2) Goffman I. Asylums. London: Anchor Books. 1961.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir
We are grateful for the helpful comments on our editorial on re-
institutionalisation in mental health care. Regarding the concern that we
used an unclear and possibly over stretched notion of the term institution
we make three points: First, there is no universally agreed definition of
the term institution and institutionalisation. Second, wherever the line
between institutionalised and non-institutionalised mental health care is
drawn, there is re-institutionalisation. If institutions are hospital
beds only, there is re-institutionalisation because the number of beds is
increasing, primarily in the forensic sector. If supported housing
schemes are also regarded as institutions, there is re-
institutionalisation because such schemes have expanded enormously. If
teams operating in the community such as Assertive Outreach are also taken
as institutions, again there is re-institutionalisation because the number
of such services is clearly rising. Third, we contrasted re-
institutionalisation with the de-institutionalisation that has dominated
mental health care reforms for 50 years.
De-institutionalisation is also
ambiguously defined and means different things to different people. Some
feel that de-institutionalisation only describes the reduction of hospital
beds, others argue that it aims to reduce all professional support in
favour of self-help and “normal” support in the community. Whatever the
precise definition of institutions are, re-institutionalisation now occurs
in contrast to former de-institutionalisation.
We have not argued that all the new institutions are necessarily bad.
We have just pointed out the new tendency in mental health care to
establish more institutions, which is shared by most western
industrialised countries. Importantly this re-institutionalisation is not
based on new evidence, but on a new philosophy and a “Zeitgeist” that has
rarely been explicitly addressed in the professional or public debate.
Yours sincerely
Stefan Priebe
Trevor Turner
Competing interests:
None declared
Competing interests: No competing interests
Sir,
Priebe and Turner stimulate thinking by asking whether community
institutionalisation is the consequence of new forms of psychiatric
intervention. However, in Scotland, for every old age hospital bed which
has been closed in the past 20 years, three have been opened in nursing
homes (1). The proportion of dementia sufferers in institutional care has
grown from 10% in 1964 (2) to 40% in 2001(3). This is incompatible with
care in the "community". More imaginative solutions are required to
improve the lot of the elderly mentally ill.
1. Wood R, Bain MRS. (2001) The Health and Well-being of Older People
in Scotland: Insights from national data. Edinburgh. Information and
Statistics Division. (available on
www.show.scot.nhs.uk/isd/Scottish_Health_Statistics/subject/older_people...)
2. Kay DWK, Beamish P, Roth M. (1964) Old age disorder in Newcastle
upon Tyne. Part 1: a study of prevalence. British Journal of Psychiatry
110: 146 – 158
3. Alzheimer Scotland Action on Dementia. (2001) Planning signposts
for dementia care services. Alzheimer’s Scotland Action on Dementia.
Edinburgh
Competing interests:
None declared
Competing interests: No competing interests
Priebe and Turner's article is stimulating and worthy of debate.
However, I consider that they overstretch the definition of "institution"
to the point of newspeak when they include within the term
"institutionalising" those of us working flexibly in assertive outreach
with people who do not automatically accept the received wisdom of
standard services.
One contributing factor to an increase in institutional care is
improved follow-up and new ascertainment of people with mental illness in
the community. However good one's community services, at least some of
these people are likely to require institutional care at some time. This
finding was evidenced in the study of Tyrer et al. (1)
Yours,
David Dodwell
(1) Tyrer P et al. A randomised controlled study of close monitoring
of vulnerable psychiatric patients. Lancet 1995;345:756-759.
Competing interests:
None declared
Competing interests: No competing interests
In their stimulating editorial, Priebe and Turner have overlooked a
major current locus of institutional psychiatric care - the prison
service. Like the expansion of forensic psychiatric services, this too has
been a global phenomenon, reported in the UK, US and Europe.
In UK prisoner populations, it has been reported that 4-10% of
remanded prisoners and 2-7% of sentenced prisoners suffer from psychotic
illnesses (1). Of course, numbers become much higher if those with
personality disrders and substance misuse are included. Figures llike
these prompted one American psychiatrist to call prisons the last mental
hospitals left open after the closure of the asylums(2).The reasons for
this development are complex; a review of the role of prisons as new
asylums from Germany(3) identified a range of factors involved in this
unfortunate development.He included changes in the provision of
psychiatric care and the reluctance of general psychiatric services to
accept mentally disordered offenders due to lack of secure accomodation,
beds and staff with appropriate skills and experience.
It would appear that it is, at least in part,a large area of still
unmet need that has driven in the expansion of forensic psychiatric
services. Rather than "sucking" resources away from those most in need of
psychiatric care, forensic services could be seen as failing to keep pace
with the mental health needs of an expanding prison population. The
appropriate manner to deliver mental health services to this neglected and
needy group is an important question for the whole of psychiatry; in the
meantime, it seems, an old institution is taking on a new role.
References
(1) Gunn J (2000) Future directions for treatment in forensic psychiatry.
Journal of Forensic Psychiatry. 176:332-8
(2) Gilligan j (2001) The last mental hospital. Psychiatric Quaterly.
72(1):45-61.
(3)Konrad N (2002) Prisons as new asylims. Current Opinion in Psychiatry.
15:583-587.
Competing interests:
None declared
Competing interests: No competing interests
EDITOR - Priebe and Turner draw attention to the urgent need for debate on some important issues. But the terms of the debate need to be clearer if it is to be fruitful. They apply the term reinstitutionalisation indiscriminately to a range of very different services, each of which itself includes a variety of activities.
There is no recognition that they may be in part alternatives to more coercive interventions. It is not ‘plain English’ to assert that potential patients of assertive outreach teams uniformly ‘want nothing to do with services’ since a proportion have hitherto been in effect denied access until admitted on Section. The equation of supported housing with private madhouses is unpleasant and contrasts with its role in producing ‘positive changes in the process of deinstitutionalisation‘ found by a study of which Professor Priebe is one of the authors (1); as well as ignoring the housing rights that are at its core and the more satisfying lives that in practice residents enjoy.
In contrast, the deinstitutionalisation side of the equation is presented very narrowly. There is no mention, for example, of the increasing participation of patients and relatives nor of the inaptly named but important Recovery movement. It is suggested that non-institutional services will eventually be restricted to well motivated patients who can afford to pay. Presumably the authors intend this as a warning rather than a recommendation, but it may be brought nearer by blanket condemnation of alternatives and by ignoring the neglect and exploitation of the most needy that prompted some ‘institutional’ developments.
Indiscriminate use of the term institutionalisation leads to underestimating its complexity, past and present(2). It is potentially divisive and demoralising for the many front-line staff who struggle to address real needs and manage to maintain patient-centred approaches even in restrictive circumstances. I would suggest that instead we unite to oppose the attempted direction of mental health services by politicians and their surrogates, which I believe is at the core of current discontents.
References
(1) Priebe, S., Hoffman, K., Isermann, M., Kaiser, W. Do long-term hospitalised patients benefit from discharge into the community? Soc Psychiatry Psychiatr Epidemiol 2002; 37: 387-392.
(2) Abrahamson, D. Institutionalisation and the long-term course of schizophrenia. Brit J Psychiat 1993; 162: 533-538.
Competing interests:
None declared
Competing interests: No competing interests
Priebe & Turner argue that, in effect, mental health services in
England have come full cycle. They leave out one further factor, the
recent organisational changes in the delivery of mental health care.
During my psychiatric training in the early 1980s there were two models
- the asylum hospitals and the new mental health units which sprang up in
most District General Hospitals. The latter, along with community care,
replaced the former and psychiatrists believed that their specialty would
at last be taken seriously by the major medical disciplines.
Twenty years on virtually all psychiatric services have been
'reconfigured'. This graceless term was meant to signify a new era in
which specialist mental health Trusts, separated from the large Acute
Trusts, would be able to forge ahead with their incomes protected from
raids by acute specialties. Instead, many of the new mental health
organisations have been formed with built-in debt and, to rub salt into
the wounds, are required to make annual efficiency savings even before
they are financially stable. 'Brokerage' (basically robbing Peter to pay
Paul) for the financial year 2002 will mean that many will start the
financial year beginning April 2003 with all development monies swallowed
up by debt re-payment. There are no financial incentives from waiting list
initiatives to soften the blow.
The upshot? Some new mental health organisations have been virtually
strangled at birth and may be forced to deliver care at sub-standard
levels. The informed debate which Priebe & Turner propose should
include an evaluation of the effects of mental health 'reconfiguration',
which may turn out to be a new form of (re-)insitutionalisation.
Declaration: Dr. Baldwin is an employee of the Manchester Mental
Health & Social Care Trust. The views expressed are his own.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir
I think that early intervention is a highest common factor both in
life and in medicine. Terminology is also not very inspiring at the
moment; "assertive outreach", "clinical governance" and "chronic disease
management", whilst being designed with improvement in mind, act as a turn
off to many. Style and content, process and outcome are all important.
As the Government becomes more and more frustrated that people of all
shapes and hues just don't seem to do what they're told by Whitehall , can
we expect possibly more and more draconian responses, when exactly the
opposite is required. The most vulnerable are surely going to get it in
the neck first?
Further, as stated, institutionalisation is sited in process not
buildings. On what basis, other than perceived need for control and the
requirement to feel that we are hitting the only targets that the SMI
agenda has so far been able to invent, can we possibly justify current
practices anyway, let alone those envisaged? Psychiatry is fast
disappearing up an anus of its own making, at a time when it is THE best
potential proponent within the NHS tent for challenging oversimplification
and antediluvian reductionist bureaucratic attitudes.
Violence and the risk behaviours related to alcohol, hypoglycaemia
resulting from poor concordance with insulin, bacteraemia, hypoxia related
to inadequate asthma management or inhaler abuse, TLE, frustration and
distress do not seem to be placed in the same frame?
There are just so many fragmenting processes at work now, in terms of
both problems and solutions, with plenty of service providers benefitting
en route as more money is piled in, when the solutions are not to be found
in the NHS alone and we need innovation and short-termism like a hole in
the head. How about a chance to consolidate something?
As someone who works in the mental health Third Sector I am also
concerned that the new institutionalisation may involve us too, as we move
towards enabling and supplying more and more services, rely upon
membership, and develop "expert patients" and self-management programmes
which may also keep people ill, rather than move them on. We need to guard
against this as much as we do about raising fears and the funding we might
like to obtain as a result for the issues we espouse?
Yours Faithfully
Dr Chris Manning
Competing interests:
None declared
Competing interests: No competing interests
Reinstitutionalisation
Dear Sir,
Priebe and Turner’s fascinating editorial entitled
“Reinstitutionalisation in mental health care” (BMJ, 2003) and the
interesting responses it received evoked many thoughts.
Israel has also been undergoing a similar process of reintegrating
individuals with mental illness back into the community, and reducing the
number of psychiatric hospital beds while creating sheltered housing
frameworks in their place.
This process has been accompanied by a great deal of ambivalence: in
conjunction with the positive aspects of discharging patients from
hospital the question arises regarding whether they are indeed being given
the opportunity to lead fuller lives over the course of time. This
concern is intensified due to the fact that the community hostels often
belong to private investors who has financial interest , unlike those of
the government hospitals.
Are we not in fact creating a kind of “community hospitalization”
framework, as the hostels will not necessarily be motivated to work
towards bringing their inhabitants to leave the hostel, after undergoing a
process of rehabilitation, and seek independent housing solutions. Thus,
one might ask, what has actually been accomplished?
In our psychiatric hospital as well, we have the sense of having come full
circle as we watch patients transferred to hostels returning to
hospitalization again.
In my opinion, the primary way to measure the success of the
deinstitutionalisation process would involve systematic research regarding
the percentage of patients who return to hospital, their psychiatric
status over time, the number of patients who advance from the hostel to
independent living, their employment status, attendance at treatment
centers, sense of satisfaction and quality of life.
While the independently run hostels and their treatment programs are in
fact being monitored, such research could help to shed greater light on
these crucial issues, which Priebe and Turner have raised in their
important article.
Sincerely,
Dr. Yuval Melamed
Lev Hasharon Mental Health Center,
Israel
Competing interests:
None declared
Competing interests: No competing interests