While I support the development of community programs for the less seriously ill, I have some strong feelings about the rapid downsizing of psychiatric wards. Emptying the institutions into the community at large should not be a matter of economics alone. Its long term effects should be thought out and questioned. Is deinstitutionalization really improving the quality of life for those who suffer from severe mental and emotional illness?
I speak as a consumer who has experienced life in a large institution and in the community. For the past 15 years I have felt quite good about my life in the community. Although not working full time, I have been meaningfully active in taking courses, participating in church activities, and volunteering my time with mental health committees. I have managed to hold down very small and very part-time jobs: cleaning and delivering ad mail. I also write as a hobby. Considering the limitations that my chronic schizo-affective condition puts on me, I feel that I am living a fairly useful and productive life as a member of the community at large.
During these last 15 years, however, I would not have called myself seriously ill. Although I suffer from a chronic schizo-affective disorder that seriously affects my concentration, stress level, and motivational drive, I have learned how to remain stable, and I have developed the discipline to engage in meaningful self-determination. This was not always the case. Between 1972 and 1979, my quality of life in the community was poor. My lifestyle resembled that of the many psychiatric patients I see living in the community today. I slept until noon or later every day, then spent the rest of the day and night wandering the streets - drifting from coffee shop to coffee shop. In terms of meaningful activities and personal relationships, I had lived better when I was a patient (six months in 1968) at the Lake Shore Psychiatric Hospital in Toronto.
In the hospital, an attendant made sure that I got up every morning, went to bed at night, took several showers a week, and had three meals a day. In the institution, I also participated in group therapy, attended a daily workshop, and went to the weekly bingos, dances, and movies (run by the hospital). The hospital also had a gymnasium for basketball and volleyball. My stay at the hospital was in the active treatment ward, but even the long term patients on the other two wards seemed to live a more meaningful and productive life than I did when living on my own in the community between 1972 and 1979. Their quality of life was better than that of many chronically ill psychiatric patients who are living in the community today.
From my experience in a large institution and my knowledge of the psychiatric sub-culture, many of the seriously ill were better off in the large hospitals than they are living on their own in the community.
To say that deinstitutionalization increases community integration is a myth. It is a basic characteristic of those who suffer from severe psychiatric illness to shun society. They are not likely to become integrated into the community at large. On their own, they will isolate themselves in their apartments, or they will huddle in small groups of equally sick psychiatric patients in donut shops. The severely ill need the protective and sheltered artificial community that can be created in a hospital environment. They will be worse off living independently in the community.
In a well run and well staffed institution, patients receive support and interaction from qualified and caring professionals and may have access (in larger hospitals) to workshops, gymnasiums and chapels. To suggest that integration into the community improves the health and well being of the mentally and emotionally ill is misleading. In reality, many who live in small group homes, special care homes, or alone do not receive an adequate level of support and interaction with healthy members of society. They do not become actively involved in community programs.
Another factor that must be recognized in severe mental and emotional illness is the lack of motivation. The seriously ill do not have the discipline to get up in the morning or to keep regular sleeping and waking hours. They do not have the inner drive to do more than sleep, roam the streets, and smoke cigarettes. They are not capable of meaningful self-determination when they are seriously ill. Even a severely depressed person is not capable of independent living. People who are emotionally or mentally ill need the directive and supportive structure of an institution.
The argument of community mental health representatives is that with increased community programs the problems of deinstitutionalization can be solved. I seriously believe that this is another myth. To provide support for those suffering from serious mental and emotional illness in the community, equal to that provided by a good, well staffed institution. Full require more money than is required by the institution. Full time support in terms of people and dollars for each person living independently in the community and needing care will far exceed the combined energies and tasks (and costs) of an effective hospital staff in an institution. With a society already sensitive to a high deficit and an excessive tax burden, it is not likely that there will be sufficient funds for the community mental health system suggested by the ministry. It is my belief that the myth should be challenged.
Deinstitutionalization is effective in lowering the quality of life for the seriously ill. While community programs benefit psychiatric patients who are highly motivated, an effective institution is more able to meet the needs of those who are seriously ill. Continued deinstitutionalization will do what it has been doing since the early 1970s, lowering the level of care and support that sufferers of severe mental and emotional illness need and deserve. I speak as someone who has no vested job interest in an institution. My concern is for the welfare and for the needs of others. I question the real costs of deinstitutionalization.
© 1995 Magpie Publishing Inc.
Reprinted with permission.
Internet Mental Health (www.mentalhealth.com) copyright © 1995-2011 by Phillip W. Long, M.D.