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PSYC*3690 Article 29.pdf

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University of Guelph
PSYC 3690
Benjamin Gottlieb

Article #: 29 Title: Mental Hospitals and Deinstitutionalization Definitions Aftercare - after hospitalization, a continuing program of treatment and rehabilitation designed to reinforce the effects of therapy and to help patients adjust to their environment Board-and-Care Home - a congregate living facility in the community for persons with mental illness, provides room, board, minimal staff supervision and sometimes medication Deinstitutionalization - the mass exodus of mentally ill persons from living in hospitals to living in the community Gravely Disabled - a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter Institutes for Mental Disease - community facilities that are usually, but not always locked. They provide 24 hour structured care, close medication supervision and at least 27 hours per week of therapeutic activity for every resident Institutionalism - a syndrome characterized by lack of initiative, apathy, withdrawal, submissiveness to authority, and excessive dependence on the institution Background - before the current era of deinstitutionalization, chronically and severely mentally ill persons were usually institutionalized for life in large state mental hospitals - in the 1960s, it was observed that persons who sent long periods in mental hospitals developed what has come to be known as institutionalism, a syndrome characterized by a lack of initiative, apathy, withdrawal, submissiveness to authority, and excessive dependence on the institution - this treatment can strip away a patientʼs dignity and individuality and foster regression, the deviant person is locked into a degraded, stigmatized, deviant role Functions of the State Hospital - the term “asylum” was in many ways appropriate, these imperfect institutions did provide asylum and sanctuary from the pressures of the world where most patients were unable to cope - they provided medical care, patient monitoring, respite for the patientʼs family, and a social network for the patient, as well as food, shelter, and needed support for structure - the treatment and services that did exist were in one place under one administration - in the community, the situation is very different - services and treatment are under various administration jurisdictions and various locations - the use of the word asylum, which has taken on such a negative connotation, needs further elaboration - the fact that the chronically mentally ill have been deinstitutionalized does not mean they no longer need social support, protection, and relief from external stimuli and the pressures of life - they need asylum and sanctuary in the community Hospital Versus Community - in the view of some, deinstitutionalized has gone too far in terms of attempting to treat long-term mentally ill persons in the community - some long-term mentally ill persons clearly require a highly structured, locked, 24 hour setting for adequate intermediate or long-term management - where to treat is a decision that is best based on the clinical needs of the person - deinstitutionalization has too often confused locus of care and quality of care - where mentally ill persons are treated has been deemed to be more important than how or how well they are treated - the long-term mentally ill are not a homogeneous population, what is appropriate for some is not appropriate for others - e.g. persons who are assaultive, lack internal controls, are self destructive may be lost to the mental health system and are on the streets and in jails - one consequence has been an alienation of a number of long-term mentally ill persons from a system that has not met their needs and some mental health professionals have become disenchanted with their treatment as well New Generation of Chronically Mentally Ill Persons - the problem that has proved most vexing and almost totally unforeseen by the advocates of deinstitutionalization, is the treatment of the new generation of severely mentally ill persons that has emerged since deinstitutionalization - the large homeless population with major mental illness has tended to be young - those who have been hospitalized for long periods have been institutionalized to passivity - for the most part they have come to do what they are told - this is not true for the new generation of severely mentally ill persons - they have not been institutionalized to passivity - not only have they not spent long years in hospitals, they have probably had difficulty just getting admitted to an acute hospital and even greater difficulty staying there for more than a short period on any one admission - when one is still young and just beginning to deal with lifeʼs demands and trying to make a way in the world, one struggles to achieve some measures of independence, to choose and succeed at a vocation, to establish satisfying interpersonal relationships and attain some degree of intimacy and to acquire some sense of identity - these efforts often only lead to failure - before deinstitutionalization, these “new chronic patients” would have been chronically institutionalized, often starting from the time of their first break down in adolescence or early adulthood - they were given a permanent place of asylum from the demand of the world - since large scale deinstitutionalization began, hospital stays tend to be brief - the majority of “new” long-term patients are the products of deinstitutionalization - it is this new generation of chronically and severely mentally ill persons that has constituted the greatest concerns about deinstitutionalization - they have posed the most difficult clinical problems in treatment and by swelling the ranks of the homeless mentally ill and the mentally ill in jail, they have created serious social problems for the community Problems in Treatment of the New Long-Term Patients - many patients fail to take psychotropic because of disturbing side effects, denial of illness, and other reasons - admitting mental illness seems to them to be admitting failure - becoming part of the mental health system seems to many of these persons like joining an army of misfits, many of these persons also have primary substance abuse disorders and/or medicate themselves with street drugs - these problems becomes worse for those whose illness is more severe, and may result in serious problems such as homelessness Basic Needs of Chronically and Severely Mentally Ill Persons in the Community - a comprehensive and integrated system of care needs to be established in the community - the following are the components of such a system - adequate, comprehensive and accessible psychiatric and rehabilitative services need to be available - first, there needs to be an adequate number of direct psychiatric services that provide: (a) outreach contact, (b) psychiatric assessment, (c) crisis intervention, (d) individualized treatment plans, (e) psychotic medication, (f) psychosocial treatment - second, there needs to be an adequate number of rehabilitative services that provide socialization experiences, training in the skills of everyday living, and social and vocational rehabilitation - third, both treatment and rehabilitative services need to be provided assertively - fourth, the difficulty of working with some of these patients should not be underestimated - crisis services need to be available and accessible - an adequate number of professionals and para
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