Reinstitutionalisation in mental health care

Since the 1950s mental health care in most industrialised countries has been characterised by deinstitutionalisation, with national reforms varying in their pace, fashion, and exact results.¹,² The development of comprehensive community mental health care is widely regarded as not yet complete. In England the national service framework and NHS Plan aim at establishing new community based services—for example, for home treatment, assertive outreach, and early intervention. Yet despite the apparent evidence of ongoing deinstitutionalisation, we argue that a new era in mental health care has already started—reinstitutionalisation. It is displaying a synonymous pattern across Europe, as with deinstitutionalisation, but this time it has been occurring largely unnoticed by the scientific community and unscrutinised by politicians and the media.

What are the signs of reinstitutionalisation? Firstly, the number of forensic beds is rising, in the United Kingdom, with dramatic increases in the private sector. Plans to increase this number further are in hand. Secure units are extremely costly, with no evidence as to their effectiveness, although we live in an era of evidence based medicine. The cost implications are sucking funds away from the more financially stretched areas, especially in London; the process is fuelled by the straitjacket of risk management despite evidence that deinstitutionalisation did not increase homicide rates in mentally ill people.³ Little systematic research has been conducted into the matter, although other countries, such as Germany and Austria, have also witnessed a steady increase in the numbers of forensic beds over the past 10 years.⁴

Secondly, attitudes to compulsory treatment have changed. The relative numbers of compulsory admissions of psychiatric patients across Europe vary by a factor of 20, but, independent of this mainly unexplained variation,⁵ compulsory admissions have risen in many, although not all, European countries including the United Kingdom. In Italy, Bavaria, and the United Kingdom new legislation or new directives to handle existing legislation have been proposed, to widen the options for compulsory treatment.^6–8

Thirdly, placements in supported housing at varying levels of dependence have increased enormously. Data as to how many and which patients are in what schemes and for how long are largely missing, and little substantial research has evaluated whether the schemes are effective in achieving whatever their precise aims are.⁹ Supported housing seems to be taking the place that used to be held by the old style asylums, and many facilities are run by private providers. This and the aforementioned rising number of privately provided secure units might lead to the conclusion that “private madhouses” are back, no matter the official names.

Fourthly, assertive outreach teams have been established throughout England. Their aim is to minimise hospitalisation and care for those patients who have been “difficult to engage” or who—in plain English—want nothing to do with services. Although teams do not formally exercise any legal power, patients are undeniably put under pressure to comply with treatment. Whatever the therapeutic intentions, administering treatment to someone who does not want it without a legal basis for compulsion poses an ethical dilemma.¹⁰ It is also a proactive institutionalising step, although the institution in this case is a community based service and not defined by bricks and mortar.

Similarly, the new early intervention teams might be seen as being in line with reinstitutionalisation. They aim to turn individuals who otherwise would not yet be treated into psychiatric patients and subjects of ongoing treatment interventions. This approach is supported by little if any research evidence¹¹ and is based on the assumption that early psychiatric treatment will prevent a more negative course of illness—an assumption prevalent among psychiatrists in the 19th century, which made them successfully demand more and bigger asylums.¹²

One might disagree with our interpretation of some of these phenomena, but it would be hard to dismiss them completely. They may provide the historical and international context for the current debate on the draft Mental Health Bill in the United Kingdom. Mental health care has entered a new era of reinstitutionalisation in its long historical balancing act between social control and therapeutic aspiration. We may now even start to witness a clearer split between the two, with an increasing market for patients who actively seek treatment and can directly or indirectly pay for it, contrasting with reinstitutionalisation for patients with more severe mental disorders who may upset the public. This split is likely to affect primary as well as secondary care.

What seems needed, in any case, is an informed debate on the values behind reinstitutionalisation and systematic research on its reasons, costs, and effects. As with research on deinstitutionalisation, a non-parochial perspective will be required alongside reliable and comprehensive data that are currently so difficult to obtain. A proper understanding of deinstitutionalisation and reinstitutionalisation can help avoid the stigmatising policies that so often marginalise mental illness.