Everyday life and critical diversities, Social Inequalities and Social Ordering

Is it still relevant to talk about deinstitutionalisation on World Mental Health Day?

By Maria Teresa Ferazzoli

Campaigns like Let’s talk have worked to reduce the stigma around mental health issues and helped to raise awareness about the importance of asking for help. However, there is still limited attention given to the experiences of people affected by severe and chronic mental illness. 

Present western mental health care systems are the result of deinstitutionalisation. In the middle of the 20th century, western psychiatric systems became the object of criticism because they conflicted with elements of the Universal Declaration of Human Rights. ‘Asylums’ were condemned because their main aim was to incarcerate, rather than treat, people affected by mental illness. As a consequence, beds in long-stay institutions were reduced, and the social rehabilitation of patients in the community became the main goal of psychiatric treatments. One of the main principles of deinstitutionalisation was the promotion of patients’ choice in decision-making about their treatment.

While current mental health care systems are founded on the same principles, people affected by severe mental illness can still be subject to compulsory treatments and sectioning. ‘Compulsory psychiatric treatments’ is an umbrella term which includes a series of forced medical treatments to which a person affected by severe mental illness might be subjected against their own will, during their life. Coercive treatment most often entails the administration of psychiatric drugs. However, physical measures, such as restraint, seclusion, caged or net-beds and electroshock, are also applied. In this regard, psychiatry represents a clear exception among other medical fields because it is the only medical discipline that gives such power to the doctor.

Compulsory treatments are practiced worldwide, including in the UK. Conversely, their use has been increasingly critiqued in relation to the principle of respect for the autonomy and liberty of the individual in decisions about medical and social services interventions (Hegarty and Brusasco, 2020). Reports also show the risk of human rights violations to people with mental and psychosocial disabilities (Drew et al., 2011). While some authors support the use of compulsory treatment, for instance in the prevention of suicide (Wang and Colucci, 2018), others point out the negative impact that these practices have on the relationship between medical professionals and patients (Drew et al., 2011). In addition, studies on the experiences of patients who were subjected to compulsory treatments show that coercion was commonly felt by patients as dehumanizing (Newton-Howes and Mullen, 2011; Murphy et al., 2017). 

However, despite legislative attempts to reduce the number of compulsory treatments, studies show that the number of people admitted to psychiatric hospitals is rising throughout Europe (De Stefano and Ducci, 2008; Sheridan Rains et al., 2019), including in the UK (Weich et al., 2017). Some authors also describe a process of reinstitutionalisation of psychiatric patients (Turner, 2004; Fackhouri and Priebe, 2007).

There is also evidence to suggest that some social groups experience this differently to others, with data showing that unequal access to services needs to be addressed in the development of community-based mental health services; for example, a study on Racial Disparities in Mental Health, commissioned by the NHS, found strong inequalities in access to mental health services for ethnic minority groups in the UK (Thornton, 2020). This is reflected in statistics published by the UK Government which showed that black people were 4 times more likely than white people to be detained under the Mental Health Act in 2020. Other UK based studies also show the correlation between poverty and hospitalisation of people affected by severe mental illness (Bindman et al., 2002; Keown et al., 2016 ). 

In simple words, those who are already vulnerable are more likely to be subject to sectioning and long hospitalisation. On the other hand, it is also important to point out that studies stated that the rates of compulsory admission and the length of stay in psychiatric hospitals are lower where there is the presence of good mental health services in the community (Bindman et al. 2002; Crossley et al., 2020)

In the light of these considerations, it is clear how deinstitutionalisation cannot be considered only as an historical event, but as a priority of national mental health care strategies. The WHO Mental Health Action Plan 2013-2030, in fact, reinforces the importance of deinstitutionalisation and the development of community-based mental health services as the main priority of mental health care reforms and implementation. Indeed, at the core of deinstitutionalisation values, there was the promotion of patients’ choice in decision-making for their treatment but also the establishment of mental health services in the community to make this possible. When the theme of World Mental Health Day is ‘Mental Health in an Unequal World’, it is crucial to talk about deinstitutionalisation and the broken promise to people affected by severe mental illness, in terms of their right to choose their treatment and create more inclusive mental health services. 

References

Bindman, J., Tighe, J., Thornicroft, G., & Leese, M. (2002). Poverty, poor services, and compulsory psychiatric admission in England. Social Psychiatry and Psychiatric Epidemiology, 37(7), 341–345. https://doi.org/10.1007/s00127-002-0558-3

Crossley, N., & Sweeney, B. (2020). Patient and service-level factors affecting length of inpatient stay in an acute mental health service: a retrospective case cohort study. BMC Psychiatry 20, 438 https://doi.org/10.1186/s12888-020-02846-z

De Stefano, A. &, Ducci, G. (2008). Involuntary Admission and Compulsory Treatment in Europe: An Overview, International Journal of Mental Health, 37:3, 10-21, DOI: 10.2753/IMH0020-7411370301

Drew, N., Funk, M., Tang, S., Lamichhane, J., Chávez, E., Katontoka, S., Pathare, S., Lewis, O., Gostin, L., & Saraceno, B. (2011). Human rights violations of people with mental and psychosocial disabilities: an unresolved global crisis. Lancet , 378(9803), pp.1664–1675.

Fakhoury, W.K., & Priebe, S. (2007). Deinstitutionalization and reinstitutionalization: major changes in the provision of mental healthcare. Psychiatry MMC, 6, 313-316.

Hegarty, L., & Brusasco, M. (2020). Life, liberty and the therapeutic relationship: examining the place of compulsory treatment in modern psychiatry. Australasian Psychiatry. doi:10.1177/1039856220924319

Keown, P., McBride, O., Twigg, L., Crepaz-Keay, D., Cyhlarova, E., Parsons, H., . . . Weich, S. (2016). Rates of voluntary and compulsory psychiatric in-patient treatment in England: An ecological study investigating associations with deprivation and demographics. British Journal of Psychiatry, 209(2), 157-161. doi:10.1192/bjp.bp.115.171009

Murphy, R., McGuinness, D., Bainbridge, E., Brosnan, L., Felzmann, H., Keys, M., Murphy, K., Hallahan, B., McDonald, C., & Higgins, A. (2017). Service Users’ Experiences of Involuntary Hospital Admission Under the Mental Health Act 2001 in the Republic of Ireland. Psychiatric services, 68(11), pp. 1127–1135.

Newton-Howes, G., & Mullen, R. (2011). Coercion in Psychiatric Care: Systematic Review of Correlates and Themes. Psychiatric Services, 62(5), pp. 465-470.

Salize, H., & Dressing, H. (2004). Epidemiology of involuntary placement of mentally ill people across the European Union. British Journal of Psychiatry, 184, pp. 163-8.

Sheridan Rains, L., Zenina, T., Dias, M. C., Jones, R., Jeffreys, S., Branthonne-Foster, S., … Johnson, S. (2019). Variations in patterns of involuntary hospitalisation and in legal frameworks: an international comparative study. The Lancet. Psychiatry, 6(5), 403–417. https://doi.org/10.1016/S2215-0366(19)30090-2

Thornton, J. (2020). Ethnic minority patients receive worse mental healthcare than white patients, review finds. BMJ, 368, m1058–m1058. https://doi.org/10.1136/bmj.m1058

Turner, T. (2004). The history of deinstitutionalization and reinstitutionalization. Psychiatry, 3(9), pp. 1-4. https://doi.org/10.1383/psyt.3.9.1.50257.

Wang, D., & Colucci, E. (2017). Should compulsory admission to hospital be part of suicide prevention strategies? British Journal Psychiatry Bulletin, 41, pp. 169-171.

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