Introduction

Over the past several decades many nations have embarked upon dedicated efforts to reduce, if not to eliminate, the role of psychiatric hospitals in the treatment of mentally ill persons. This movement, popularly known as ‘deinstitutionalisation’, has greatly altered the lives of psychiatric patients throughout the Western world. This chapter will examine the history and current status of the deinstitutionalisation movement and identify some specific problems that may be traced directly to the implementation (often incomplete or faulty) of deinstitutionalisation policy. A ‘new chronic’ patient population will be described, and the positive legacy of deinstitutionalisation will be noted. The chapter will conclude with a plea for a new, more realistic understanding of what successful deinstitutionalisation must entail. This discussion is based largely on service delivery trends in the United States. However, both the popular and professional literature (Thornicroft & Bebbington, 1989; Schmidt, 1992; Thornicroft et al.1993), as well as extensive personal observation, suggest that other countries are encountering similar circumstances. Precisely why this is so is an intriguing question that merits serious consideration, in view of vast differences in nations’ health care philosophies and service delivery practices. One may speculate that there are common issues in serving psychiatric patients in the community that transcend national boundaries, and that these must be frankly examined for their broader implications.

Deinstitutionalisation: definition and background

Deinstitutionalisation, which refers to a complex series of interrelated events and policy decisions, may be defined as the replacement of long-stay psychiatric hospitals with smaller, less isolated community-based service alternatives for the care of mentally ill individuals. In theory it consists of three component processes: the release of patients residing in psychiatric hospitals to alternative facilities in the community; the diversion of potential new admissions to the alternative facilities; and the development of special community-based programmes, combining psychiatric and support services, for the care of a non-institutionalised patient population (Bachrach, 1976). The last of these processes is held to be particularly important, for it is assumed that patients’ altered life circumstances will inevitably result in new configurations of service need.