The social wave

At the end of the Second World War there was a great desire for social change; one of its aspects was the belief that everyone had a 'right to health' or at least the right to receive adequate medical care regardless of ability to pay. This resulted in the creation of the National Health Service in the United Kingdom in 1948 and the Social Security system in France, together with similar developments in other countries. The social perspective, which was one of the basic principles underlying these developments, initiated major institutional changes in psychiatry. They were the result of a number of factors—the necessity to give to the whole population an easy access to psychiatric care, and also the belief that social elements played an important role in the aetiology of the mental disorders and that they could greatly contribute to the healing process, with the aim of progressively reintegrating the patient in the community.

The most spectacular aspect of the new policy was the decline of the asylum system, still in a dominant position in psychiatry; in fact, the number of patients in psychiatric hospitals in the developed countries reached its peak in 1955. The criticisms of the 'degeneration' of the functioning of psychiatric hospitals and the segregation of patients in institutions often located far from their homes and families were not new. However, the previous partial improvements, such as the decrease in the number of compulsory commitments or the creation of outpatient departments, were replaced by the creation of completely new structures. Ideally, the country would be divided into geographical zones or sectors with a population of about 100000, and each zone would have a multidisciplinary team of psychiatrists, nurses, clinical psychologists, social workers, and occupational therapists responsible for mental health. Visits and therapeutic interventions in the patient's home and easily accessible outpatient departments were to play an increasingly important role. If hospitalization was necessary, it should be as far as possible in small units located in a general hospital where the time of stay was to be reduced to the absolute minimum. Special institutions such as day hospitals, night hospitals, and specially adapted workshops would contribute to the progressive readaptation of the patient to the life in the community. The introduction of this 'community care', which was expected to work in close co-operation with general practitioners and various public and private institutions, would result in the disappearance of the traditional psychiatric hospital and to 'deinstitutionalize' psychiatry. The new system was introduced in various forms in most countries after 1969. In the United States the Community Mental Health Center Act was promulgated in 1967. In the United Kingdom, which had strong traditions of social psychiatry, plans for the implementation of community care were discussed in the 1960s, and in 1975 the Government White Paper Better Services for the Mentally Ill encouraged the formation of multidisciplinary 'primary care teams' which also included general pratitioners. In France, an official directive in 1960 created the psychiatrie de secteur which was expected to result in the progressive elimination of hospitalocentrisme. The World Health Organization (WHO) encouraged all its member countries to adopt similar practices.

Although in the last 40 years community care has become the official doctrine everywhere, except in Japan where the rate of hospitalization in mostly private hospitals has grown continuously, its implementation has not been easy despite the major therapeutic improvements brought about by pharmacotherapy. In some parts of the United States the sudden closure of public psychiatric hospitals combined with the inadequacies of the Community Mental Health Centers were for a time at the origin of an appalling lack of care for a number of mentally ill people. The expected 'fading out' of hospitalization has been slow. According to the WHO, in 1976 the number of mental health beds (including beds for the mentally retarded) per 1000 population was 6.5 in Sweden, 5.5 in the United Kingdom, 3 in France, and 2 in Germany. These figures have since decreased and the types of hospitalization have changed. In 1955, 77 per cent of the 'psychiatric care episodes' in the United States occurred in public psychiatric hospitals, compared with 20 per cent in 1990. In 1994, 1.4 million mental patients were hospitalized, but only 35 per cent in public psychiatric hospitals compared with 43 per cent in general hospitals and 11 per cent in private psychiatric hospitals, which increased in number from 150 in 1970 to 444 in 1988. In France, where the total number of psychiatric patients treated in public institutions (including children) is now about a million, 60 per cent are seen exclusively on an ambulatory basis, but the number of hospital beds has only been reduced by half.

Reflecting the increasing influence of social perspectives, the organizational changes modified psychiatry as a profession. The increase in the number of psychiatrists in private practice was paralleled, in general to a lesser extent, by an increase in the public sector where their role was modified. In the traditional asylum the authority of the psychiatrist was unchallenged and limited only by the legal provisions related to the procedures of commitment. The nurses, and later the clinical psychologists, social workers, and occupational therapists, were 'paramedical auxiliaries' in a subordinate position. The creation of multidisciplinary teams, working in various settings, gave the psychiatrist a function of co-ordination made increasingly complex by the claims of professional autonomy made by the former auxiliaries. In some cases, such as in the American Mental Health Centers, the psychiatrists who were a small minority in the team and had less and less control over its functioning, resented what they considered to be the loss of their medical status.

The importance given to social factors was not limited to the system by which care was delivered. Sometimes, combined with radical ideological and political attitudes, it took more extreme forms. The criticisms, which first centred on the inadequacies of the existing institutions, extended to the concept of mental disease itself. The antipsychiatric movement claimed that mental diseases were artificial constructs which were not related to diseases in the medical meaning of the term. The allegedly pathological behaviours, such as those conceptualized as schizophrenia, were in fact normal reactions to an inadequate social system. The so-called treatments were techniques used by the ruling classes to preserve the social order of which they were the beneficiaries. The only solution was a drastic reform of society. Such theses varied in their content and in the arguments used. They were developed by authors such as Szasz, Laing, and Cooper in the English-speaking world, the philosopher Foucault in France, and the psychiatrist Basaglia in Italy. They reached their greatest influence in the 1960s and a few attempts were made to put their ideological principles into practice. Although they attracted much attention at the time, they were very limited and short lived. One of the few countries where this movement had a practical impact was Italy. Basaglia's strongly politically oriented theories were influential in the later legal reform of the antiquated asylum system, but, despite the apparently revolutionary character of some of the new administrative provisions, the changes made were very similar to those taking place in other countries.

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