For centuries, the care of mentally ill people was largely behind what are now thought of as the “forbidding gates” of asylums. This is somewhat ironic since the advent of the Asylums (providing a place of sanctuary) was initially a major advance in the humane care of the mentally ill. They relieved the community of the burden of patient care; nursing, protecting and maintaining the survival of the mentally ill.
For the latter part of the last century in particular, changes in ideology have placed mental hospitals under tremendous pressure. Ongoing criticism, together with financial and other measures, has moved the focus of care back to the concept of community-based services. In spite of the enthusiasm behind the concept, care in the community has taken over 30 years to establish and still has to fully prove its place as an effective approach to the care of the mentally ill. An urgent re-evaluation of the mental health-care system is necessary, to ensure suitable care of the mentally ill.
Decline in popularity of mental hospitals, and the growing scandals of sub-standard care provided in these institutions, started in the 1930s. A number of factors contributed towards this normous change:
The introduction of pharmacological treatments, like phenothiazines in 1957, is believed to have profoundly influenced the role of the institutions. The bed occupancy in both the United Kingdom and the United States peaked in the mid 1950s, and has consistently fallen subsequently. Attributing the down turn of bed occupancy entirely to the advent of effective anti-psychotic medication is an oversimplification, particularly since the rates began to fall in the early 1950s.
The growing concern was that the mental hospitals were prolonging and adding to the disabilities caused by mental disorders. The most influential work came from Irving Goffman who criticised the pathological features of institutions and introduced the concept of Total Institutions characterised by:
In the 1960s the mental hospitals came under increasing pressure by a series of scandals, revealing cruel and degrading treatments in long-stay mental hospitals. The anti-psychiatry movement (e.g. Thomas Szasz, R.D.Laing) challenged the validity and utility of psychiatric diagnosis. At the same time, publicity surrounding treatments such as psychosurgery and electroconvulsive therapy added to the society’s distaste for the then standard practice.
The policy of deinstitutionalisation continued, and the change in the Government’s approach was highlighted by the Member of Parliament Enoch Powell’s much-noted speech in 1961, when he foresaw the “demolition of brooding mental hospitals and their replacement by modern and acceptable services”.
Wing and Brown illustrated that an under-stimulating environment might actually be harmful by contributing to the social handicaps of the chronic patients. Their well-known three hospitals study compared the outcome results of three different hospitals which had very different styles of patient care.
The developments in the United Kingdom (e.g. incorporation of mental health services into the National Health Service (1948) and Mental Health Act (1959)), emphasised the integration of social and health provision. These were paralleled with similar changes in the rest of Europe and the United States:
The American Community Mental movement launched by President J. Kennedy arrived at similar policy changes. Italian Reforms - Law 180 (1978) stimulated massive shift of emphasis in mental care in the north of Italy. The radical decision to completely close all asylums has led to a highly controversial outcome.
The first official use of the term community care was in the Annual Report of the Board of Control (of mental hospitals) in 1930. The concept developed with the decline of the mental hospital population, and has recently gained further momentum. The term is imprecise, however, and controversial.
The traditional functions of mental hospitals have not and cannot be totally replicated in the community. Treatment of patients in the community is certainly possible, and the emphasis has been on rehabilitation, developing after-care programmes, and shifting the resources towards services in the community (reprovision). The Team for the Assessment of Psychiatric Services (TAPS Project) is the most carefully researched reprovision exercise the United Kingdom. Using cohorts of “leavers” and “stayers”, the progress of 278 chronic patients with serious mental illness in Friern, Barnet and Claybury Hospitals has been studied. Those who were discharged into the community after extensive stays in hospital (movers), were meticulously monitored and compared with matched patients who remained in hospital (stayers). Most patients had schizophrenia. While a substantial proportion were re-admitted for brief periods, very few were lost to follow-up or became homeless. Patients demonstrated a modest increase in their level of social interaction and a marked improvement in satisfaction with their lives and treatment.
At 1-year follow-up, movers and stayers had the same death rate. Movers showed no significant improvement in psychiatric symptoms, but preferred their accommodation and the ability to be able to choose what to do with their time. The costs were about 10% less than that of in-patient care. After 2 years there was also a suggestion of improvement in aspects of their clinical functioning.
There are a number of well conducted studies offering patients community support as an alternative to hospital admission (reviewed by Braun et al.). Important problems with these studies include:
Community care has been exposed to large amounts of press coverage and public criticism. The scandal were highlighted and dramatised where the services seem inadequate to provide effective care of the mentally ill in the community.
Sensational headlines like “One murder a Fortnight by mentally ill” (Daily Telegraph), called for immediate action after 34 murders by the mentally ill over 18 months. Many were recently discharged and had recent contact with the psychiatric services prior to the incidents.
In response to mounting criticism during the 1980s, the Government produced a White Paper entitled Caring the People.
There has been further legislation in the NHS and Community Care Act (1990). Local authorities are now required to produce and Publish community care plans for their area, to provide assessments of people likely to require community care services, and care management systems. The care programme approach (CPA) had its origins in the Spokes Inquiry into the care and aftercare of Sharon Campbell. Its recommendations led to the publication of a document by the Royal College of Psychiatrists. This document Provides a framework for good practice in delivering care to People accepted by psychiatric services. CPA involves:
Patients who are discharged after being in hospital for 6 months or more.
Patients who have complex needs requiring multi-disciplinary management. Collaboration and regular review will be facilitated by a formal care programme.
A community supervision order was proposed by the Royal College of Psychiatrists to ensure that “at-risk” patients maintain their treatment outside hospital and would permit early compulsory readmission to re-establish treatment if necessary. This was rejected by the Government after objections from pressure groups such as MIND on the basis of whether such an approach would infringe the rights of patients to refuse treatment. It was argued that such statutory powers might encourage lazy clinical practice, create an overemphasis on drugs, increase ethnic discrimination and create problems with consent similar to those with Section 7 (guardianship) orders.
Supervised community treatment (SCT) was introduced into the MHA by the Mental Health Act 2007. It allows a person who has been detained under certain sections of the MHA to be discharged back into the community under a community treatment order (CTO). The person must comply with certain conditions or face being recalled (brought back) to hospital and being detained once again under their original section.
Other possibilities to enhance care in the community included extended leave of absence and guardianship.
The Clunis inquiry recommended special supervision to monitor high risk groups. The criteria proposed that certain patients be closely monitored:
Treatment has been transferred to the community but the traditional function of custodial care has not. The need to protect some people from their own actions when ill, and to protect the public from others, will always be there. “Special hospitals” and prisons are facing increasing demands, and it is likely that the community care debate will continue for many years.