'De-institutionalization' and the community: fact and theory

Community care for the mentally ill in England and Wales: myths, assumptions and reality

It is widely recognised that there are many problems with the community care policy for the mentally ill which has been in operation in England and Wales since the late 1950s. However, many existing accounts of the development of the policy rest upon a variety of erroneous assumptions about how it has evolved, and which in turn affect our understanding of how it might be changed. Some of these assumptions are examined, and it is argued that frequently they fail to acknowledge how both the rhetoric and the reality of the policy have developed. Taking this critique into account, a more accurate assessment of how to understand community care for the mentally ill is offered.

The chronic mental patient: the position of th Canadian Psychiatric Association

The Canadian Psychiatric Association recommends: 1. In this International Year of Disabled Persons, that the needs of the chronic neural patient be publicized with emphasis on the potential for improvement if these needs are adequately met. A working definition of the chronic mental patient refers to those members of society who suffer from a chronic mental illness and who demonstrate significant impairment of task performance and/or social performance. 2. A comprehensive network of services should be developed including provision for basic need with a range of housing options, inpatient and outpatient psychiatric evaluations and treatment, personal clinical support, living-skills training and vocational assessment and training. Aside from patient needs, the professional status of the caregivers involved is to be enhanced. Laudable efforts by self-help groups should be further encouraged. 3. Community resources should be enlisted following principles and practices identified as basic to successful programs already existing, for example: -- provision of economic stability -- presence of administrative leadership -- striving for continuity of care -- allowance for adequate manpower -- establishment of vocational supports -- respect for patients' rights -- provision of community education -- design of ongoing evaluation and research 4. A greater emphasis should be placed in undergraduate and postgraduate medical and psychiatric training programs on the treatment of the chronically ill. 5. The Canadian Council on Hospital Accreditation should continue to elaborate and publish criteria by which services to the chronically mentally ill would be evaluated both at the inpatient and outpatient levels. These criteria when available should be promoted in all relevant institutions.

Social deprivation amongst short stay psychiatric patients

Two samples of newly admitted psychiatric patients were examined. Of 558 patients admitted during one year, 76 (13.7 per cent) came in from transitory accommodation or no fixed abode; of 456 patients discharged 131 (28.7 per cent) either changed address during their stay in hospital or left without known accommodation. Of 102 patients in the wards and day hospital on one day, 29 (28.4 per cent) came in from transitory accommodation or no fixed abode, 66 (64.7 per cent) were unemployed, 51 (50 per cent) were living alone. Of the 74 inpatients 30 (40.5 per cent) were homeless and 27 (36.5 per cent) had no visitors. These results indicate that many patients have lost their community supports by the time they reach hospital.

Organization and interaction in psychiatric day centres

One of the major problems in the care of chronic patients is the design of suitable long-term environments. Following from the work of Tizard and his colleagues, a study is described which investigated the aspects of the organization, management practices and social interactions in 4 local authority day centres for the care of chronic patients in the community. It was found that these centres differed markedly in terms of their organization and management practices and that these differences were correlated with the nature and quality of staff-client (although not staff-staff) interactions. Client-oriented management attitudes were correlated with a more personal approach to clients' problems and a warmer quality of interaction. These differences did not seem attributable to different kinds of clients being involved in each centre. The results are discussed in terms of the possible causal mechanisms involved and their implications for designing systems of long-term care.