Wednesday, May 19, 2021

Reversing re-institutionalisation

I’ve always tended to prefer the term de-hospitalisation to de-institutionalisation, because although the traditional asylums have closed, institutional practices still exist in the network of community, including smaller residential, facilities that have replaced them. In fact, since 1990 there has been a re-institutionalisation of mental health services, particularly with increasing numbers of secure psychiatric beds both in the NHS and private sector. For example, Rutherford & Duggan (2008) reported that the "forensic services population rose by 45% in the 10 years between 1996 and 2006". This resort to re-institutionalisation, as Turner (2004) said, partly “reflects a culture of risk management, [and] an overriding concern for public safety ... “ (see previous post). 

Despite the move to community care and the reduction in both mental illness and learning disability in-patient beds overall, the number of detentions under the Mental Health Act (MHA) 1983 continues to rise (Keown et al, 2018). This is one of the major reasons why the MHA is currently being reformed. Alongside the increase in detentions, the proportion of involuntary admissions to private hospitals increased from 3% in 1984 to 15% in 2015/6. This shift was more pronounced for forensic (Part III) patients, although also occurred for civil (Part II) cases.

Of course, part of the motivation for the rundown of the traditional asylum was the institutionalisation of patients. The new MHA needs to bring a halt to their re-institutionalisation and do more to improve the process of de-institutionalisation started by the 1959 and 1983 Acts. The White paper has talked about the warehousing of patients, primarily for learning disability patients, although this also occurs for those with serious mental illness. To complete the quote from Turner (2004) above, the other reason for re-institutionalisation is “the burdens and pressures upon services trying to manage ‘revolving-door’ psychotic patients”. These patients are seen as difficult to manage and place and have been shipped out of the NHS to private care and to low and even medium security, when they should be managed in a more open door-environment. As I have said (eg. see previous post), civil detentions of people with learning disability and serious mental illness should be prohibited to secure provision. This will allow secure services to develop their proper function of providing a therapeutic alternative to prison. The 2007 amendments to the Act, which were motivated by an inappropriate over-concern with risk, need to be reversed by repealing community treatment orders (see another previous post).

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