Posts Tagged ‘ deinstitutionalization ’

Le branle-bas général à Saint-Jean-de-Dieu : Expérience de la désinstitutionnalisation, 1930-1976

Expérience de la désinstitutionnalisation à Saint-Jean-de-Dieu

Le branle-bas général à Saint-Jean-de-Dieu: Expérience de la désinstitutionnalisation, 1930-1976

Conférence de Marie-Claude Thifault

Le mercredi 03 juin 2015 – 19 h à 20 h 30

Institut Universitaire en Santé Mentale de Montréal

Conférence grand public

«Ouvrir les portes de l’hôpital, débarrer les portes de l’hôpital», selon le psychiatre Denis Lazure, n’était pas une façon d’imager sa pensée, mais bien un geste concret nourri par le vent de changements qu’insufflait la révolution psychiatrique des années 1960. Certes, la Commission d’études des hôpitaux psychiatriques et les conclusions de son rapport (Bédard, 1962) permettaient de croire à un vaste projet de désinstitutionnalisation psychiatrique au Québec. Nous jugeons qu’il est à propos de déplacer le point de vue sur la question de cette grande réforme pour s’intéresser à celui du patient lui-même. Cela afin de nous demander quelles sont ses propres inquiétudes quant à l’avenir suite au processus institutionnel de mise en liberté définitive? Ce questionnement propose une réévaluation des résultats peu concluants qu’a connus la première vague de désinstitutionnalisation psychiatrique au Québec, cette fois-ci, attachée à relater et prendre en compte l’expérience des patients.

Cette présentation sera tirée du livre Désinstitutionnalisation psychiatrique en Acadie, en Ontario français et au Québec (PUQ, 2014)


Marie-Claude Thifault, professeure agrégée
Titulaire, Chaire de recherche sur la francophonie canadienne en santé
Directrice, Unité de recherche sur l’histoire du nursing, Faculté des sciences de la santé, Université d’Ottawa, Canada

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Is This the Worst Time Ever to Have a Severe Mental Illness?

Psychiatrist Allen Frances, Professor Emeritus at Duke University and Chair of the DSM-IV Task Force, has published a new article in The Huffington Post today centered on the history of psychiatry. The piece also features the work of University of Toronto historian of medicine Edward Shorter. It is entitled “Is This the Worst Time Ever to Have a Severe Mental Illness?”

Is This the Worst Time Ever to Have a Severe Mental Illness?

My personal response to this depressing question would have to be an ashamed ‘Yes’ for the United States; a relieved ‘No’ for most of the rest of the developed world.

Admittedly, though, I am not the best person to provide a long view answer. We will soon be turning to Professor Edward Shorter, an eminent historian of psychiatry, to compare our current mistreatment of the severely ill with the practices of past epochs.

But I can speak from painful experience about the slippery downward slope of the past 50 years. When I first began work as a medical student on a psychiatric ward, we were very very optimistic that three new advances would dramatically improve the lives of our patients: 1) the availability of effective medication; 2) the availability of powerful research tools; and 3) the hope that state hospitals would disappear as patients were deinstitutionalized into the community.

Forty years ago, my optimism collided with reality when I was given charge of a short term inpatient ward. The medicines sometimes did work wonders, but often brought only partial relief and caused unpleasant side effects. The research findings were fascinating, but didn’t have any impact on patient care. And worst of all, it was clear from the outset that deinstitutionalization was being carried out so badly it was bound to fail.

Patients were irresponsibly discharged at breakneck speed with little or no provision for their housing or treatment in the community. They were left to sink or swim on their own and not surprisingly many sank.

The dream of deinstitutionalization turned into nightmare because most state governments didn’t, as promised, use the money saved by closing beds to provide adequate community treatment and housing. Deinstitutionalization was great for the state budget, but often terrible for the patients.

Many wound up on our unit. I am still haunted by a man I had to cut down after he had hanged himself in our shower room — he couldn’t tolerate his fallen status from chief car washer in the state hospital to deinstitutionalized street person.

In Europe, deinstitutionalization was usually done much better — with a sense of social justice, adequate funding, decent housing, and greater family involvement. Originally, there were also some excellent programs in the United States, but most of these have been eroded with time under pressure from shrinking budgets and the cherry picking of easier patients that accompanied privatization.

The severely ill are now often jailed or homeless — worse off than they were when I started psychiatry. For more on this heartbreaking development, see this blog post and a dozen others I have written.

Now we’re going to shift gears from my personal experiences to Edward Shorter’s historical perspective. He is professor of the history of medicine and professor of psychiatry at the University of Toronto and has written widely on the past and current problems of psychiatry. Professor Shorter writes:

“What was it like being a psychiatric patient in the remote past? Before 1800, before Philippe Pinel, things were quite grim. People often believed that mental symptoms were caused by demonic possession and took the ill to priests for painful, sometimes fatal, exorcism. Psychiatric patients were sometimes, if female, regarded as witches and burned at the stake.

Physicians, while not believing in demons, thought the abdomen — especially the spleen and colon — was the site of mental illness and treated patients with laxatives. Bleeding and many other futile and dangerous treatments were also routine.

There were no dedicated mental hospitals. Patients who needed to be swept off big-city streets were thrown into ‘hospices,’ together with the criminal, the medically sick, the elderly, and the poor. In smaller communities, mentally affected relatives might simply be locked in the attic or chained in the barn.

A fantasy has arisen among the followers of Parisian philosophy professor Michel Foucault that traditional societies viewed the mentally ill benignly — permitting them to drink red wine on the village commons all afternoon as the neighbors looked on smilingly. In the Foucauldian version of history, the downward slide of the mentally ill begins with ‘capitalism’ and the modern state, as the former benignly neglected denizens of the village commons were now ‘confined’ in barrack-like asylums.

Nothing could be further from the truth. Around 1800, proper mental hospitals were founded. These were intended to be, and originally were, humane institutions-the well-ordered routines of a hospital would restore a sense of order and normalcy; its high walls would grant a sense of safety; and medical reassurance constituted an early form of psychotherapy.

The wheels started to come off the wagon when these praiseworthy intentions were overwhelmed by the sheer press of numbers. Yet a core reality remained: For many, the asylum was a place of safety.

Since deinstitutionalization and the death of the asylum, the care of very ill psychiatric patients has gotten much worse. Psychiatry’s dirty secret is that if you had a severe mental illness requiring hospital care in 1900, you’d be better looked after than you are today. Despite a flurry of media hand-waving about new technologies in psychiatry, the average hospital patient probably does less well now, despite the new drugs, than the average hospital patient a century ago.

How can this be? Above all, the old asylums were committed to keeping the patients safe. A major source of mortality (aside from tuberculosis) was suicide, and the best way to preserve patients from suicide is to hold onto them until they are better. As David Healy’s research group has determined, in one British mental hospital around 1900, the average stay was 302 days, versus 41 days in the same hospital today. Suicide rates within ten years of discharge are much higher now despite the availability of drugs. In 1900, among patients with schizophrenia, 4 had killed themselves within ten years of discharge; today in a roughly similar population, it was 29. Note that most psychiatric inpatient units in the US now have a length of stay that has been shortened to an incredible 7 days — far too short to stabilize patients and keep them safe.

I am not trashing today’s psychopharmaceutical palette. Many patients are clearly better off with drugs than without them. Yet the crucial factor here is length of stay: the stays then were long (sometimes far too long); the stays now are ultra-brief and patients are discharged well before they are able to cope — especially since so few services are available in the community and adequate housing is in such short supply.

The old institutions were not wonderful — they were overcrowded, noisy, and often had a distinctive odor. Patients were neglected and mistreated. Yet those problems have been replaced with a different set: patients today are far too often relegated to jails and prisons, where their vulnerability leads to frequent solitary confinement and physical and sexual abuse. Patients used to work at productive jobs within the institutions; no longer available now that we’ve abolished the shelter the hospitals provided.

When in the 1970s the hospital administrators and state legislators began the massive program of deinstitutionalization — returning the patients to the community — it was under the pretense that they were being discharged to ‘community care,’ to a network of halfway houses and day clinics where they would be looked after and kept safe.

Guess what? Never happened. The well-meant institutions of community care foundered and sank, sometimes because of lack of money, or an antipsychiatry inspired belief that there was no such thing as mental illness and that problems could be treated with kindness alone. I am not against kindness, but some patients are very ill and need genuine medical treatments. Many patients today, booted from the former security of the asylum, find themselves on the street with no care at all or in prison. This is a national scandal and the term “progress in psychiatry” turns out to be cruelly ironic.”

Thanks so much, Professor Shorter, for providing this brief but illuminating historical context. There are two contradictory views on the study of history: 1) If we don’t learn from history, we are doomed to repeat it, versus 2) The one thing we learn from history is that we don’t learn from history. I am inclined to believe the second, but am unwilling to give up on the possibilities suggested by the first.

To read the rest of this article, click here.

New Book Announcement: Closing the Asylums (George Paulson)

McFarland & Company has just published a new book by George Paulson, Closing the Asylums: Causes and Consequences of the Deinstitutionalization Movement (214 pp. Paperback, $45).

George Paulson is an internationally known neurologist who worked in and about state mental hospitals during the revolutionary movement to close those hospitals. He combines his personal observations with historical scholarship to produce a fresh perspective on a major change in society and medicine.

The press describes the book this way:

One of the most significant medical and social initiatives of the twentieth century was the demolition of the traditional state hospitals that housed most of the mentally ill, and the placement of the patients out into the community. The causes of this deinstitutionalization included both idealism and legal pressures, newly effective medications, the establishment of nursing and group homes, the woeful inadequacy of the aging giant hospitals, and an attitudinal change that emphasized environmental and social factors, not organic ones, as primarily responsible for mental illness.

Though closing the asylums promised more freedom for many, encouraged community acceptance and enhanced outpatient opportunities, there were unintended consequences: increased homelessness, significant prison incarcerations of the mentally ill, inadequate community support or governmental funding. This book is written from the point of view of an academic neurologist who has served 60 years as an employee or consultant in typical state mental institutions in North Carolina and Ohio.

Deinstitutionalisation in psychiatry as a possible resource

A Romanian – Italian symposium of Psychiatry took place at the University of Medicine and Pharmacy “Carol Davila” (Bucharest) on November 25-26 2010. Here is the program:


Romanian – Italian symposium of Psychiatry

University of Medicine and Pharmacy “Carol Davila”- Aula Magna

(Bucharest, 25th and 26th November 2010)


8.45 – 10.10

Arrival of participants, introduction speeches

Panel 1

The Romanian and Italian experience of deinstitutionalisation in psychiatry

Chairman: Prof. Dr. Pompilia DEHELEAN, Head of The Romanian Association of Psychiatry and Psychotherapy, Pro-rector and Head of the Department of Psychiatry, UMF “Victor Babes” Timisoara


Matt MUIJEN, Regional Adviser for Mental Health WHO Regional Office for Europe – Challenges for community based mental health services in Europe


Prof. Dr. Ileana BOTEZAT ANTONESCU, President of the Romanian Federation of Psychotherapy, Director of The National Centre of Mental Health and Fight against Drugs Bucharest – Deinstitutionalization in mental health services in Romania – between aspiration and reality


Dr. Lorenzo TORESINI, psychiatrist ASL Merano – Deinstitutionalisation in Italy: Franco Basaglia and the introduction of ethics in the medical treatment


Prof. Dr. Dan PRELIPCEANU, Medical Director at “Prof. Dr. Alexandru Obregia” Psychiatry Hospital Bucharest – A reformation project of the mental health services – sources, solutions, and limits. A critical approach.


Prof. Dr. Luigi ATTENASIO, Director of the Mental Health Department of the ASL Rome C, National President of „Psichiatria Democratica Europa”

Dr. Walter GALLOTTA, Director of the psychiatric hospital service unit “Diagnosis and Treatment” S. Giovanni Hospital, Rome

Dr. Angelo DI GENNARO Basaglia theories and practices in a Mental Health Department of a metropolitan city: towards the implementation of international development programmes in co-operation with an NGO (CESVI)


Dr. Patrizia D’ONOFRIO, psychologist, ASL E Rome – Changes in the role of the care function following the law no. 180: an impressive challenge and a creative engagement


Dr. Roberto MEZZINA, Director of the WHO Collaborating Centre – Trieste Mental Health DepartmentDeinstitutionalization in East European countries: the role of WHO Collaborating Centre of Trieste in the reform process


Dr. Bogdana TUDORACHE, President of the Romanian League for Mental Health and Raluca NICA, psychologist, Director of the Romanian League for Mental Health – The role of NGOs in the development of mental health in Romania


Public debate


Lunch break

Panel 2

Overcoming contention as a milestone for deinstitutionalisation

Chairman: Prof. Dr. Tudor UDRIŞTOIU, Scientific secretary UMF Craiova


Dr. Bruno NORCIO, Deputy Director of Mental Health Department of Trieste and former Head of Psychiatric Emergency Service – Overcoming of contention. How can it be done?


Dr. Gaetano INTERLANDI, psychiatrist Caltagirone Catania – SPDC no restraint in the middle of a decentralised organization


Prof. Dr. Luigi ATTENASIO, Director of the Mental Health Department of the ASL Rome C, National President of „Psichiatria Democratica Europa”, Dr. Walter GALLOTTA, Director of the psychiatric hospital service unit “Diagnosis and Treatment” S. Giovanni Hospital, Rome and Dr. Angelo DI GENNARO – Reciprocity: against containment and in favour of  the dialogue with madness


John JENKINS, President of the International Mental Health Collaborating Network (IMHCN) – Whole life-recovery approach in community mental health


Prof. Dr. Florin TUDOSE, Dean of Psychology and Sociology Faculty, ”Spiru Haret” University Bucharest – Immobilization and contention as an aggression


Prof. Dr. Mirela MANEA, Head of the Department of Medical Psychiatry and Psychology, the Faculty of Dentistry UMF “Carol Davila” Bucharest – The careful surveillance versus the close observation for the patients with mental disorders


Public debate


End of the first day



Arrival of participants


The speech of Prof.Dr. Virgil PAUNESCU, Presidential Counsellor

Panel 3

Treatment through social inclusion. Cooperation, self-support, social assistance.

Chairman: Dr. Gianfranco PALMA, Director of the Mental Health Department ASL E Rome


Prof. Dr. Aurel NIREŞTEAN, Head of Department and General Chancellor UMF Tg. Mures – Deinstitutionalization and de-stigmatization


Dr. Gianfranco PALMA, Director of the Mental Health Department ASL E Rome – Changes in the culture and welfare systems in the process of social inclusion


Dr. Ruggero BRAZZALE, psychologist, Bassano del Grappa – Innovation models in the mental health services in the Mures region: the Marostica project.


Vasile GAFIUC, President of The Regional Association of Adult Education, Suceava – The role of NGOs in the process of decentralisation of the psychiatric system


Dr. Ilario VOLPI, psychologist, President of the integrated cooperative “Il Grande Carro” in Rome – Integrated cooperatives and the process of deinstitutionalisation


Dr. Mircea DRAGAN, Ploiesti Municipal Hospital – Disorganization in mental health from Prahova County


Coffee break


Dr. Jean-Yves FEBEREY, Head of Department, Henri-Guérin Hospital (Department of Var, France), doctor at Centre médical de la Mutuelle Générale de l’Education Nationale – Disorganization in mental health in France today


Prof. Dr. Alexandru PAZIUC, Psychiatric Hospital Campulung Moldovenesc – The role of the mobile team in the process of social inclusion of people with severe mental problems


Dr. Magda GHEORGHIU, MD Psychiatric Hospital Siret – Attempts to reintegrate people mentally retarded from institutions


Dr. Luigi LEONORI, psychologist, President of SMES-Europe – Psychic suffering and precariousness: prevention and  participation


Public debate


Lunch break

Panel 4

De-institutionalization in Eastern Europe and CIS States

Chairman: Prof. Luciano Sorrentino, Director of Mental Health Department “Franco Basaglia” ASL TO2, Professor of History of Psychiatry, Psychology Department, University of Torino


Dr. Nermana MEHIC-BASARA, MSc, neuropsychiatrist, Director of the Institute for Alcoholism and Substance Abuse of Sarajevo Canton, Bosnia and Herzegovina – From Centralised Services toward Community Based Psychiatry – Experiences from Bosnia and Herzegovina


Manana SHARASHIDZE M.D, psychiatrist, Director of the Georgian Association for Mental Health – Opportunities and obstacles for future de-institutionalization in Georgia


Dr. Markku SALO, Head of Research, The Finnish Central Association for Mental Health – From charity to productivity of persons. The importance of the protagonist in the individual


Public debate


Final remarks and conclusions of the symposium


Dr. Lorenzo TORESINI

Dr. Patrizia D’ONOFRIO

To see the pdf of the program, click here.

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