What+impact+has+deinstitutionalisation+had+on+the+well-being+of+mental+health+patients?

**//Student number: 7219008//** **//Tutor: Michelle Newcomb//**
 * //Name: Holly Butcher//**

**//“//**//…..the essence of physicianhood is putting the good of the patient first.// //Just how far medicine has deviated from this principle is evident from a// //single distressing fact:// //“Patients with serious mental illness die 25 years earlier than the// //general population.” (Parks et al. 2006).// //They die from psychiatric, medical, and social neglect. If anything, the// //problem is worsening (Saha et al 2007). Neglect leads to unrecognized and// //untreated cardiovascular and respiratory diseases, to diabetes and its// //complications, to infectious diseases including HIV, to substance abuse, and to// //other diseases that afflict the ill-housed, the ill-fed, and the abandoned (Brown et// //al. 1999; Brown et al. 2000; Osborn et al. 2007). Care of the severely mentally ill// //should have been the focus of our professional careers; advocacy for their rights// //should have been our role as citizens. Instead, we have engaged in solipsistic// //debates about brain versus mind – about psychotherapy versus drugs – about// //genes versus environment. Preoccupied with our theories and ourselves, we// //abandoned the sickest patients”.// Leon Eisenberg (2009) ‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍- Professor of Psychiatry and Social Medicine, Emeritus, Harvard Medical School, Boston, Massachusetts, USA. ‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍

**__Topic:__**
** Mental Health: ** How has society improved their treatment of persons with mental health problems and what impact has deinstitutionalization had in this process?

=**__Artefact:__**=



This picture depicts a group of men wearing strait jackets within a lunatic asylum. A strait jacket is a garment typically made from heavy material such as canvas, with long sleeves which have been sewn shut to confine the hands. The garment is firmly strapped shut by lacing the arms across the chest and tying the sleeves together behind the back, restricting almost all arm movement. Strait jackets were commonly used with padded cells by the end of the nineteenth century as a means of restraint for people with mental disorders who were assumed to be capable of causing harm to themselves or others (Pilgrim, 2005).

=**__Public Health Issue:__**=

This artefact represents the inhumane treatment of people with mental disorders and is symbolic of just how far we have come in terms of mental health treatment. This essay will report on the negative stigma associated with mental health patients in history and today. It will critically analyse the impact of mental health issues on the population and discuss what has been done to improve the health and treatment of those living with a mental illness. Furthermore, it will investigate the controversial history of institutionalised lunatic asylums followed by the movement of deinstitutionalisation as a step towards social justice and respect for human rights, consequently questioning its success.

=**__Literature Review:__**=

 D efined by the World Health Organization (2011), "mental health is not just the absence of mental disorder. It is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, work productively and fruitfully, and is able to make a contribution to his or her community". People with mental disorders are a group that have been exposed to significant human rights violations in the past but what is even more concerning is the evidence suggesting the continued ostracising and inequalities faced by those suffering mental health problems today (World Health Organisation, 2011).

 The 2007 National Survey of Mental health and well-being conducted by the Australian Bureau of Statistics (2008) found that around 45% of the population aged between 16 and 85 had experienced a mental health disorder within their lifetime. It was estimated to be responsible for 13% of the total burden of disease in Australia in 2003, ranking third among the major disease groups, behind cancer and cardiovascular disease (Begg, Vos, Barker, Stevenson, Stanley & Lopez, 2007). It was also reported that the incidence of long term mental and behavioural problems has increased progressively since 1995 (Australian Institute of Health and Welfare, 2010). However, it is difficult to conclude a definitive increase in prevalence of mental health problems due to insufficient data, people not reporting their disorder or seeking health care due to the stigma surrounding mental health, as well as the changing understanding of what defines a mental health problem (Aneshensel & Phelan, 1999). These alarming statistics place mental health among Australia’s National Health Priority Areas (AIHW, 2011).

If these statistics are not indication enough of the importance of addressing mental health within Australia, the unequal distribution of prevalence across population subgroups places another degree of significance on top of the issue. According to Begg et al. (2007) there were marked sex differences in the mental illness burden for particular disorders with the burden from anxiety & depression being twice as high for females as for males. Conversely, the burden from substance abuse was more than three times as high in males as in females (Begg et al., 2007). Aboriginal and Torres Strait Islanders, men in rural areas and unemployed people were also reported to have higher rates of mental illness (ABS, 2008). The greatest numbers of people with a mental illness are within the eighteen to twenty four age group, with prevalence declining with age (ABS, 2008). The high incidence within this age group may be attributable to the number of transitions and significant change occurring in this period of life (McGorry, Parker, & Purcell, 2011).  Deinstitutionalisation is a process associated with mental health care which involves the movement from caring for the mentally ill in an institutional setting (previously known as ‘lunatic asylums’) to the treatment and care of patients within the wider community (Australian Government, 2010). This movement was important as it was widely recognisable that institutional care which dominated mental health treatment in the 20th century was unacceptable, being prohibitively costly, isolating, neglectful and sometimes abusive and punitive (Aneshensel & Phelan, 1999). Doessel, Scheurer, Chant and Whiteford (2005) conducted database research on mental institution admissions and discharges from the 1950’s to the present. Admissions are associated with the allowance of patients into the institutes where discharges involve removing patients from institutionalised care by placing them in a community based health setting (Doessel et al., 2005). Their results suggest that deinstitutionalisation of the mental health system was most rapid in the thirty year period between 1950 and 1980 by an increase in institute discharges and a decrease in admittances. Doessel et al. (2005) concludes that the process of deinstitutionalisation was virtually completed by the time the government’s National Mental Health Strategy was developed and implemented in 1992, with only slow changes occurring subsequent to this.

This research by Doessel et al. (2005) is quite controversial as the government claims that deinstitutionalisation was a major component of the National Mental Health Strategy, providing a step towards an environment for mental health patients which is both conducive to health and delivers basic human rights (Australian Government, 2010). A journal article by Robert Reich (as cited in Doessel et al., 2005) suggests the extensive expansion of community mental health services needed within the new strategy was necessary in order to provide services for those patients who were helplessly and inhumanely discharged into the hostile community prior to the development of a competent community health care model (prior to 1992). It only seems logical to suggest that the government had eased much pressure off themselves by allowing deinstitutionalisation to occur prior to their strategy implementation, as there would be less people to provide immediate community resources for when the asylums ‘officially’ began closing down. Johnson (1998) introduces two conflicting views on the deinstitutionalisation of mental health, which lead him to conclude that deinstitutionalisation is a rather problematic process. He explains deinstitutionalisation as being made up of two incompatible discourses; those being the concern for the rights of the mentally ill opposed to the concern for the appropriate management of the mentally ill. The latter depicts a discourse which tends to contradict the underlying purpose of deinstitutionalisation; that being the management of the people, resources and places in order to ‘control’ where and what environment is suitable for the patient (Johnson, 1998). Kirk and Einbinder (1994) support this ‘management’ discourse, arguing that deinstitutionalisation barely took place. Instead, the chronically mentally ill whose disruptiveness and economic burden could not be dealt with in the community were simply shifted to private custodial institutions. Battams (2010) and Pilgrim (2005) describe this act of ‘reinstitutionalisation’ to obtain profound inhumanity, with no improvement in human rights for these patients in comparison to the institutionalised approach.  Gostin (2008) asserts that the assumption of the broader community to be accepting of deinstitutionalization and community integration had a major impact on its effectiveness. This was due to minimal public awareness of mental health problems resulting in considerable negative stigma and discrimination towards those affected. Another problem arose from the assumption that family members of the mentally ill had the skills and knowledge necessary to make the best decision for their relatives care and placement within the community (Gostin, 2008). Finally, Gostin (2008) describes the incongruous effect on the people living in the institutions. It was assumed that deinstitutionalisation was in the best interests of the patients with no consideration for the patients who had called these institutions home for several years and felt frightened to leave the lifestyle they knew so well.

=**__Cultural and Social Analy__****__sis:__** =

The shameful history surrounding the maltreatment and social exclusion of persons with mental illness continues in today’s society through discrimination and negative stigma from stereotypes of incompetency and dangerousness (Pilgrim, 2005). Gostin (2008) believes this public perception to rob people with mental health problems of their dignity; that being "the right to control the most fundamental aspects of life such as bodily integrity and personal or financial affairs". It also provides policy makers an ostensible justification to exercise ‘control’ over these people, even if they have not committed an offence, due to a lack of diversionary options and a low tolerance by the courts and society for this class of offenders (Butler, 2006).

Gostin (2008) explains the result of these societal perceptions following deinstitutionalisation to be a causal factor of the transmigration of mentally ill persons into new institutional settings such as jails, remand centres and homeless shelters. This is seen within Australia in a study conducted by Butler, Andrews, Allnut, Sakashita, Smith and Basson (2006) showing the prevalence of psychiatric illness in the last year being 80% for prisoners and 31% within the community. These substantial statistical differences place further apprehension on the effectiveness of deinstitutionalisation. This may be considerably due to the extreme pressure placed on a community which was not well enough equipped to handle such a large change in structure and management of mental health.

Lennane (2005) describes deinstitutionalisation as "a large-scale social experiment with no oversight by ethics committees, let alone the subjects’ informed consent". The implications experienced by those suffering with mental illness today are compared by Lennane (2005) to the practising of formal euthanasia, due to the repudiation of adequate treatment for suicidal people with mental health problems. This controversial comparison is based on figures showing suicide rates of people theoretically under the care of communal mental health services to have trebled in the last twelve years (Lennane, 2005).

Gostin (2008) clearly demonstrates the importance of cultural acceptance of mental illness as it is a powerful predictor of how well people will be treated and integrated into society. His observational research compares the deplorable treatment of mentally ill persons in Japan compared to the amiable treatment of the mentally ill in India. He concludes that the reason for such abysmal treatment in Japan was due to the societal view that mental illness was a matter of shame whereas India’s culture was to care for the mentally ill within the family and community.

The previous paragraphs have maintained focus on the negative aspects associated with the deinstitutionalisation of mental health. It is important to recognise both the positive and negative outcomes of this movement, as there is much community ignorance surrounding the latter and consequently, it often goes unspoken of (Corrigan, 2004). Raising awareness of the injustice of human rights and eliminating the stigma still affecting this vulnerable population provides the first steps towards equality (Corrigan, 2004). Mental health problems not only have an impact on the patient but place profound stress and responsibility on the patient’s friends, family and the broader community (Australian Bureau of Statistics, 2009). For this reason, public health experts need to work collaboratively with all sectors of the community in order to provide the most appropriate community health care model guided by the government's National Mental Health Strategy. By remaining aware of the past negative outcomes associated with attempts to improve the human rights of mental health patients, recurring problems may be avoided and advancements will be made primarily on the basis of improving the lives of mentally ill persons.

=**__Artefact Analysis/ Learning Reflection__**= = = My artefact is symbolic in terms of expressing the changes of mental health treatment throughout history. It provokes curiosity into the historical treatment of mentally ill persons and the changes which have occurred in order to improve their treatment. This curiosity uncovered several negative aspects of the deinstitutionalised approach which mentally ill patients are still facing today. In my opinion, it is sickening to read of the inhumane and callous treatment of persons with mental disorders around the world. Furthermore, it is somewhat disturbing and confusing to reveal social injustices and prejudice to be apparent within their treatment and management in Australia at present.

<span style="color: windowtext; font-family: arial,helvetica,sans-serif; font-size: 120%;">By critically analysing this research topic, I have come to the conclusion that government practises and policies may not be as socially just as they portray. Behind the government’s plans to improve the human rights of the mentally ill, there are strong economic and management motives attached to their decisions. In addition, the government regards any place which attracts negative social comments (such as lunatic asylums) as ‘difficult to manage’ (Johnson, 1998). It is likely that this also had a significant influence on the governments push towards deinstitutionalisation (Johnson, 1998). This assessment piece will influence me to refrain from making quick judgements on what is first portrayed to me in all areas of life. It is important to view any social issue from a range of different contexts in order to develop my own hypothesis on why and how it came to be.

=__Reflection Task__=

Wiki: Throwing like a girl... who knew it wasn't socially applicable?
I like that you have explained many of the current gender inequalities not only in women’s sport, but within the broader community. I agree with Ian Wellard’s theory on the importance of targeting gender inequality associated with sport from the place where these disparities began; that being in school. I began my first degree in physical education teaching and a common theme which arose was discussion on the most appropriate way of avoiding the negative stereotypes females receive from participating in sport. It is so important for physical education teachers to provide a learning environment promoting physical activity for both genders which aims at eliminating the stereotypical views of masculinity and femininity.

Wow. You have really done well to choose an artefact that is creative in evoking thought. Well done! I find it astonishing that there are still so many people out there engaging in sexual activity without being ‘safe’. It is understandable that in certain parts of the world it may be more difficult to protect yourself against STI’s as the appropriate resources are not readily available. For those living in westernised societies such as Australia, where medication and protection such as condoms are readily available, the high rates of STI’s do not seem coherent. I agree that it is very unfortunate that young individuals are irresponsibly prioritising sexual pleasure before their personal health and well-being and I feel that this is the main factor causing Australia's high STI prevalence rates. Hopefully, the media awareness campaigns will make some sort of positive impact but the responsibility essentially lies with the individual.

=**__Links__**=

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 120%;">Australian Institute of Health and Welfare- Mental Health <span style="color: red; font-family: Arial,Helvetica,sans-serif; font-size: 120%;">[]

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 120%;">Australia’s National Mental Health Strategy <span style="color: red; font-family: Arial,Helvetica,sans-serif; font-size: 120%;">[]

=**__Reference List__**=

<span style="display: block; font-family: arial,helvetica,sans-serif; font-size: 120%; text-align: left;">Aneshensel, C, & Phelan, J. (1999). //Handbook of the sociology of mental health.// New York: Springer Science and Business Media. <span style="display: block; font-family: arial,helvetica,sans-serif; font-size: 120%; text-align: left;">Australian Bureau of Statistics. (2008). //National survey of mental health and wellbeing of Australians: Summary of results.// Retrieved from [] <span style="display: block; font-family: arial,helvetica,sans-serif; font-size: 120%; text-align: left;"> Australian Bureau of Statistics. (2009). //Australian social trends, 2009.// Retrieved from [] <span style="display: block; font-family: arial,helvetica,sans-serif; font-size: 120%; text-align: left;">Australian Government. (2010). //National mental health strategy.// Retrieved from [] <span style="display: block; font-family: arial,helvetica,sans-serif; font-size: 120%; text-align: left;"> Australian Institute of Health and Welfare. (2010). //Mental health services in Australia.// Retrieved from [] <span style="color: windowtext; display: block; font-family: arial,helvetica,sans-serif; font-size: 120%; text-align: left;">Australian Institute of Health and Welfare. (2011). //Mental Health//. Retrieved from <span style="display: block; font-family: arial,helvetica,sans-serif; font-size: 120%; text-align: left;">[] <span style="display: block; font-family: arial,helvetica,sans-serif; font-size: 120%; text-align: left;"> Battams, S., & Henderson, J.(2010). The physical health of people with mental illness and 'the right to health’. Advances in Mental Health(1837-4905), //9//(2), 116. Retrieved from []

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">Begg, S., Vos, T., Barker, B., Stevenson, C., Stanley, L., & Lopez, A. (2007). Burden of disease and injury in Australia in the new millennium: measuring health loss from diseases, injuries and risk factors. Retrieved from <span style="font-family: Arial,Helvetica,sans-serif; font-size: 16px;">[]

<span style="display: block; font-family: arial,helvetica,sans-serif; font-size: 120%; text-align: left;">Butler, T., Andrews, G., Allnutt, S. Sakashita, C., Smith, N., & Basson, J.(2006). Mental disorders in Australian prisoners: a comparison with a community sample. //Australia and New Zealand Journal of Psychiatry////,// //40//(3), 272–276. Retrieved from [] <span style="display: block; font-family: arial,helvetica,sans-serif; font-size: 120%; text-align: left;">Corrigan, P.(2004). How stigma interferes with mental health care. The American psychologist(0003-066X), //59//(7), 614. doi: 10.1037/0003-066X.59.7.614 <span style="display: block; font-family: arial,helvetica,sans-serif; font-size: 120%; text-align: left;"> Doessel, D., Scheurer, R., Chant, D., & Whiteford, H. (2005). Australia's National Mental Health Strategy and deinstitutionalization: some empirical results. Australian and New Zealand journal of psychiatry(0004-8674), //39//(11-12),989. doi: 10.1111/j.1467-8446.2009.00254.x <span style="display: block; font-family: arial,helvetica,sans-serif; font-size: 120%; text-align: left;">Eisenberg, L (2009). //Six quotes from Leon Eisenberg.// Retrieved from [] <span style="display: block; font-family: arial,helvetica,sans-serif; font-size: 120%; text-align: left;"> Johnson, K(1998). Deinstitutionalisation: The management of rights. Disability & Society(0968-7599), //13// (3), 375 Retrieved from [] <span style="display: block; font-family: arial,helvetica,sans-serif; font-size: 120%; text-align: left;">Kirk, S., & Einbinder, S. (1994). //Controversial issues in mental health.// Needham Heights, MA: Allyn & Bacon <span style="display: block; font-family: arial,helvetica,sans-serif; font-size: 120%; text-align: left;">Lennane, J. (2005). Mortality in mental illness. //Internal Medicine Journal.// //35//(12) 733-734. doi: 10.1111/j.1445-5994.2005.00967.x <span style="display: block; font-family: arial,helvetica,sans-serif; font-size: 120%; text-align: left;"> McGorry, P., Parker, A., & Purcell, R. (2011). Youth Mental Health Services. Retrieved from [] <span style="color: windowtext; display: block; font-family: arial,helvetica,sans-serif; font-size: 120%; text-align: left;">Pilgrim, D. (2005). //Key concepts in mental health.// London: SAGE Publications Ltd. <span style="display: block; font-family: arial,helvetica,sans-serif; font-size: 120%; text-align: left;"> World Health Organisation. (2011). Mental health. Retrieved from []