Deinstitutionalisation and the move to community care: comparing the changing dimensions of mental healthcare after 1922 in the Republic of Ireland and England.

The advent of deinstitutionalisation and the introduction of community care in the latter part of the twentieth century have revolutionised mental-health service provision across Europe, although implementation, timing and services have varied widely in different countries. This article compares the changing dimensions of mental-health provision in post-independence Ireland with that in England, and will shed light on the current state of mental healthcare in both countries. The article calls for more research into the impact of deinstitutionalisation, such as the challenges faced in the community for those in need of continuing care.

Developing a Structure of Essential Services for a Child and Adolescent Mental Health System.

Policy Points That child and adolescent mental health services needs are frequently unmet has been known for many decades, yet few systemic solutions have been sought and fewer have been implemented at scale. Key among the barriers to improving child and adolescent mental health services has been the lack of well-organized primary mental health care. Such care is a mutual but uncoordinated responsibility of multiple disciplines and agencies. Achieving consensus on the essential structures and processes of mental health services is a feasible first step toward creating an organized system.

Psychiatry's Past Can Be Psychiatry's Future.

In the last half of the 20th century, psychiatry lost many of the conditions needed for unhindered practice. I compiled from searches of the literature the 20th century changes in the arenas of psychiatric practice and the sources of these changes. I determined how these changes are shaping 21st century health and well-being. The neglect of the severely mentally ill, first in Bedlams and now on Boulevards, reflects a wide loss of resources. Psychiatry's patients have lost a past of community-based mental health services, interdisciplinary care teams, preventive consultation with social agencies, and, with reimbursements targeted for 15-minute visits, time adequate with the physician to individualize diagnosis and treatment. With the Covid-19 and other epidemics, economic inequalities, an economic crisis, unrest over police violence, and racism, psychiatry can find in its past the resources to engage 21st century psychiatric and other problems.

Public mental health care in colonial Lesotho: themes emerging from archival material, 1918-35.

This paper identifies some of the themes that emerge from a study of official archival records from 1918 to 1934 on the subject of mental health in colonial Lesotho. They include: difficulties experienced by colonial medical doctors in diagnosing and treating mental illnesses, given the state of medical knowledge in the nineteenth and early twentieth centuries; impact of shortage of financial and other resources on the establishment and operation of medical services, especially mental health care; convergence of social order, financial and medical concerns as influences on colonial approaches to mental health care; and the question of whether Basotho colonial society saw institutionalization of their relatives as 'hospitalization' or 'imprisonment'. Two case studies are presented as preliminary explorations of some of the themes.

The history of mental health policy in Turkey: tradition, transition and transformation.

This article offers a brief history and the evolution of mental health policy in Turkey. It aims to analyse how mental health policies were transformed and why certain policies were introduced at specific times. The modern history of mental health policy is divided into three periods: the institutionalization of psychiatry and hospital-based mental health services; the introduction of community-based mental healthcare services; and lastly, the policy of deinstitutionalization after the 1980s. These periods have been categorized in a way that basically coincides with Turkey's modern political history.

Population-Based Approaches to Mental Health: History, Strategies, and Evidence.

There is growing recognition in the fields of public health and mental health services research that the provision of clinical services to individuals is not a viable approach to meeting the mental health needs of a population. Despite enthusiasm for the notion of population-based approaches to mental health, concrete guidance about what such approaches entail is lacking, and evidence of their effectiveness has not been integrated. Drawing from research and scholarship across multiple disciplines, this review provides a concrete definition of population-based approaches to mental health, situates these approaches within their historical context in the United States, and summarizes the nature of these approaches and their evidence. These approaches span three domains: (a) social, economic, and environmental policy interventions that can be implemented by legislators and public agency directors, (b) public health practice interventions that can be implemented by public health department officials, and (c) health care system interventions that can be implemented by hospital and health care system leaders.

An end to coercion: rights and decision-making in mental health care.

The United Nations Convention on the Rights of Persons with Disabilities requires a paradigm shift from a medical model of disability to a social model that emphasizes overcoming the barriers to equality created by attitudes, laws, government policies and the social, economic and political environment. The approach adopted by the social model recognizes that people with psychosocial disabilities have the same right to take decisions and make choices as other people, particularly regarding treatment, and have the right to equal recognition before the law. Consequently, direct or supported decision-making should be the norm and there should be no substitute decision-making. Although recent mental health laws in some countries have attempted to realize a rights-based approach to decision-making by reducing coercion, implementing the Convention on the Rights of Persons with Disabilities can be challenging because it requires continuous refinement and the development of alternatives to coercion. This article reviews the impact historical trends and current mental health frameworks have had on the rights affected by the practice of involuntary treatment and describes some legal and organizational initiatives that have been undertaken to promote noncoercive services and supported decision-making. The evidence and examples presented could provide the foundation for developing a context-appropriate approach to implementing supported decision-making in mental health care.

La Convention des Nations Unies relative aux droits des personnes handicapées nécessite un changement radical pour passer d'un modèle médical du handicap à un modèle social mettant l'accent sur la levée des obstacles en matière d'égalité, créés par des attitudes, des lois, des politiques gouvernementales ainsi que l'environnement social, économique et politique. L'approche adoptée par le modèle social reconnaît que les personnes présentant un handicap mental ont le même droit de prendre des décisions et de faire des choix que les autres, notamment en matière de traitement, et ont droit à une reconnaissance égale devant la loi. Par conséquent, la prise de décision directe ou accompagnée doit être la norme et il ne doit exister aucune prise de décision substitutive. Bien que certains pays aient récemment cherché, à travers des lois sur la santé mentale, à instaurer une approche fondée sur les droits en matière de prise de décision en réduisant la coercition, la mise en œuvre de la Convention relative aux droits des personnes handicapées peut poser problème, car elle exige une amélioration continue et l'élaboration de solutions autres que la coercition. Cet article examine l'impact que les tendances historiques et les cadres actuels en matière de santé mentale ont eu sur les droits lésés par la pratique du traitement involontaire et décrit plusieurs initiatives législatives et organisationnelles qui ont été prises pour promouvoir les services non coercitifs et la prise de décision accompagnée. Les données et les exemples présentés peuvent servir de fondement à l'élaboration d'une approche adaptée au contexte pour mettre en place la prise de décision accompagnée en matière de soins de santé mentale.

La Convención de las Naciones Unidas sobre los Derechos de las Personas con Discapacidad requiere un cambio de paradigma, de un modelo médico de discapacidad a un modelo social que haga hincapié en la superación de las barreras a la igualdad creadas por las actitudes, las leyes, las políticas gubernamentales y el entorno social, económico y político. El enfoque adoptado por el modelo social reconoce que las personas con discapacidad psicosocial tienen el mismo derecho a tomar decisiones y a elegir como cualquier otra persona, especialmente en lo que se refiere al tratamiento, y tienen derecho a un reconocimiento igualitario ante la ley. Por lo tanto, la toma de decisiones directa o apoyada debería ser la norma y no debería haber un responsable sustituto de la toma de decisiones. Aunque las recientes leyes sobre salud mental de algunos países han tratado de aplicar un enfoque basado en los derechos para la adopción de decisiones mediante la reducción de la coerción, la implementación de la Convención sobre los Derechos de las Personas con Discapacidad puede ser un reto, ya que requiere un continuo perfeccionamiento y el desarrollo de alternativas a la coerción. Este artículo evalúa el impacto que las tendencias históricas y los marcos actuales de salud mental han tenido sobre los derechos afectados por la práctica del tratamiento involuntario y describe algunas iniciativas legales y organizativas que se han emprendido para promover servicios no coercitivos y apoyar la toma de decisiones. La evidencia y los ejemplos presentados podrían servir de base para desarrollar un enfoque apropiado al contexto para la implementación de la toma de decisiones apoyada en la atención de la salud mental.

The Michigan infant mental health home visiting model.

Selma Fraiberg's pioneering work with infants, toddlers, and families over 40 years ago led to the development of a field in which professionals from multiple disciplines learned to work with or on behalf of infants, very young children, their parents, and the relationships that bind them together. The intent was to promote social and emotional health through enhancing the security of early developing parent-child relationships in the first years of life (Fraiberg, 2018). Called infant mental health (IMH), practitioners from fields of health, education, social work, psychology, human development, nursing, pediatrics, and psychiatry specialize in supporting the optimal development of infants and the developing relationship between infants and their caregivers. When a baby is born into optimal circumstances, to parents free of undue economic and psychological stressors and who are emotionally ready to provide care and nurturing for an infant's needs, an IMH approach may be offered as promotion or prevention, with the goal of supporting new parent(s) in developing confidence in their capacity to understand and meet the needs of the tiny human they are coming to know and care for. However, when parental history is fraught with abandonment, loss, abuse or neglect, or the current environment is replete with economic insecurity, threats to survival due to interpersonal or community violence, social isolation, mental illness, or substance abuse, the work of the IMH therapist may require intervention or intensive treatment and becomes more psychotherapeutic in nature. The underlying therapeutic goal is to create a context in which the baby develops within the environment of a parent's nurturing care without the psychological impingement that parental history of trauma or loss or current stressors such as isolation, poverty, or the birth of a child with special needs, can incur.

Introduction to the special section: The development of infant mental health home visiting in Michigan state government.

This issue of the Infant Mental Health Journal presents the first papers from a tripartite evaluation study of state-sponsored infant mental health home visiting program in Michigan, United States. This series of studies has been led by Kate Rosenblum PhD and Maria Muzik MD, Department of Psychiatry, the University of Michigan and faculty from the Michigan Collaborative for Infant Mental Health Research for the State of Michigan, Department of Health and Human Services, Mental Health Services for Children, to fulfill the requirements of state legislation (State of Michigan Act No. 291, Public Acts of 2013) that required that all home visiting programs meet certain requirements to be established as an evidence-based practice. In this introduction, we provide a historical context for the delivery of infant mental health home visiting through the community mental health system in the state of Michigan.

Beyond the asylum and before the 'care in the community' model: exploring an overlooked early NHS mental health facility.

This article discusses the Admission and Treatment Unit at Fair Mile Hospital, in Cholsey, near Wallingford, Berkshire (now Oxfordshire). This was the first new hospital to be completed in England following the launch of the National Health Service. The building was designed by Powell and Moya, one of the most important post-war English architectural practices, and was completed in 1956, but demolished in 2003. The article relates the commission of the building to landmark policy changes and argues for its historic significance in the context of the NHS and of the evolution of mental health care models and policies. It also argues for the need for further study of those early NHS facilities in view of current developments in mental health provision.

History of Psychopharmacology.

We live in an age of psychopharmacology. One in six persons currently takes a psychotropic drug. These drugs have profoundly shaped our scientific and cultural understanding of psychiatric disease. By way of a historical review, we try to make sense of psychiatry's dependency on psychiatric drugs in the care of patients. Modern psychopharmacology began in 1950 with the synthesis of chlorpromazine. Over the course of the next 50 years, the psychiatric understanding and treatment of mental illness radically changed. Psychotropic drugs played a major part in these changes as state hospitals closed and psychotherapy gave way to drug prescriptions. Our review suggests that the success of psychopharmacology was not the consequence of increasingly more effective drugs for discrete psychiatric diseases. Instead, a complex mix of political economic realities, pharmaceutical marketing, basic science advances, and changes in the mental health-care system have led to our current infatuation with psychopharmacology.

Schizophrenia Infrastructures: Local and Global Dynamics of Transformation in Psychiatric Diagnosis-Making in the Twentieth and Twenty-First Centuries.

This article uses the concept of "diagnosis infrastructures" to propose a framework for narrating the history of schizophrenia as a global category in the twentieth century. Diagnosis infrastructures include the material and architectural arrangements, legal requirements, and professional models that enable both the ways in which patients come to clinics and navigate the world of schizophrenia as well as the means through which clinicians organize their diagnostic work. These infrastructures constitute a framework for how schizophrenia has been identified as a disorder. This article explores three moments in the history of schizophrenia infrastructures in the twentieth century. The first is the German psychiatrist Kurt Schneider's discussion of first- and second-rank symptoms in the interwar period. The second is the research on criteria for defining schizophrenia within the framework of the WHO International Pilot Study of Schizophrenia at the turn of the 1970s. The third corresponds to the changing infrastructures of mental health care in the context of both global mental health and the changing landscape of schizophrenia research over the last decades.

Introduction.

This article offers an overview of the life and work of Gerald N. Grob. As part of a generation of scholars intent on overturning the old "Whig history" of medicine, Grob pioneered the use of institutional history as an analytical tool. His work on American psychiatry combined a formidable command of archival sources with a strong commitment to putting medical practice in social context. Grob's personal and political views put him at odds with other scholars of the asylum; he conducted some very public feuds with David Rothman and Andrew Scull. At the same time, he showed a more benevolent side to younger historians interested in psychiatry; he took particular pains to encourage women (including the authors of this introduction) to enter a historical specialty then dominated by men. To honor Grob's legacy as a scholar and a person, this special issue features articles written by several generations of scholars influenced and inspired by his work.

Psychiatric Jim Crow: Desegregation at the Crownsville State Hospital, 1948-1970.

The Crownsville State Hospital, located in Maryland just outside of Annapolis, provides a thought-provoking example of the impact of desegregation in the space of the mental hospital. Using institutional reports, patient records, and oral histories, this article reconstructs the three phases of desegregation at Crownsville. First, as a result of its poor conditions, lack of qualified staff, and its egregious mistreatment of patients, African American community leaders and organizations such as the NAACP called for the desegregation of the care staff of Crownsville in the late 1940s. Second, the introduction of a skilled African American staff created unprecedented and morally complex issues about access to psychiatric therapeutics. Last, in 1963, Health Commissioner Dr. Isadore Tuerk officially desegregated patients in all Maryland state hospitals. Though desegregation brought much needed improvements to Crownsville, these gains were ultimately swamped by deinstitutionalization and the shift towards outpatient psychiatric care. By the 1970s, Crownsville had returned to the poor conditions that existed during segregation.

Homosexuality and Psychoanalysis Meet at a Mental Hospital: An Early Institutional History.

Psychoanalysis and homosexuality in the United States were both largely in flux between 1910 and 1935. This article sheds light on this unique historical moment by first exploring scholarly discussions of the era's psychoanalysis and homosexuality, both of which emphasized the transitional nature of therapy and sexuality. By putting two bodies of scholarship into conversation, I also suggest how the historiography might move beyond two oft-cited arguments-that the psychoanalysis of the era had the power to form a person's sexual identity negatively, and that sexual minorities formed their identities affirmatively by staying away from medical interventions. I argue that, instead, psychoanalysis was part of modern sexual identity-formation in surprisingly open-ended ways. The second half of the article continues to explore the interplay between therapy and sexuality by closely examining clinical practices at one of the leading mental hospitals of the era: Sheppard and Enoch Pratt Hospital in Towson, Maryland, where an eclectic mode of psychotherapy was actively employed to treat homosexuality. In particular, the work of Harry Stack Sullivan (1892-1949), a gay psychiatrist well-known for his interpersonal theory of mental illness, shows how male patients who experienced same-sex sexual relationships nurtured productive interdependency among men in their articulation of sexual identity. By carefully delineating this process, the article shows how analytic practices could, and sometimes did, offer a crucial space for self-reflection and articulation of male sexuality.

New Directions in the Historiography of Psychiatry.

Gerald Grob's work in the history of psychiatry over the course of almost fifty years created a model for how historians might successfully situate mental health in its social and political context, and how inseparable it was from this context. Over the last twenty years, the field has grown tremendously. Historians have incorporated categories of analysis like gender and race, methodologies like cultural history and intellectual history, and sought to continue Grob's quest to understand American mental health history as a critical component of American history writ large. In this piece, we suggest several potential areas for future study. Building on Grob's work on the asylum, we focus on the continued need to explore the texture of lived experience for both practitioners and those experiencing mental illness, both within and beyond the institution. In an era when the politics of deinstitutionalization continue to shape the modern mental health enterprise, we suggest that further examination of the consequences of deinstitutionalization is both inherently rich and relevant to contemporary mental health practice. Finally, we discuss opportunities for historians to engage with policymaking and social justice, pointing to incarceration and juvenile justice as two especially relevant areas for further study.

Pathologizing the Crisis: Psychiatry, Policing, and Racial Liberalism in the Long Community Mental Health Movement.

The community mental health movement has been generally regarded as a benevolent movement that replaced old notions of psychiatric racism with new ideas about the normality of race. Few studies, however, have explored the movement for its active support for new surveillance and policing strategies, particularly broken windows theory, a policing approach partly responsible for the expansion of prisons in the United States after the 1970s. Looking to racially liberal approaches to psychiatry in the 1960s and 1970s crafted by integrationist psychiatrist Louis Jolyon West and black nationalist psychiatrist J. Alfred Cannon at the University of California, Los Angeles, this essay demonstrates that cultural and biological explanations for racial violence in civil rights and black nationalist discourses renewed surveillance on poor people of color that resulted in increased forms of incarceration, segregation, and discrimination for them by the 1980s. Rather than forward racial justice, I argue that psychiatric discourses arguing for the racial sameness of white and black minds in the 1960s and 1970s relied on scientific and cultural narratives centered on child development, gender, and sexuality that obscured the processes of racial capitalism that continued to produce poverty and sickness in black communities.

The Final Years of Central State Hospital.

There is a rich literature on the deinstitutionalization movement in the US but few, if any, parallel histories of state mental hospitals. Under attack from the 1950s on, state hospitals dwindled in size and importance. Yet, their budgets remained large. This paper offers a case study of one such facility, Indiana's Central State Hospital, between 1968 and 1994. During these years, local newspapers published multiple stories of patient abuse and neglect. Internal hospital materials also acknowledged problems but offered few solutions. In 1984, the US Department of Justice intervened, charging Central State with having violated patients' civil rights, the first such action filed under the 1980 Civil Rights of Institutionalized Persons Act. Although Indiana signed a consent decree promising major reform, long-lasting change proved elusive. Civil and criminal lawsuits proliferated. In 1992, as Central State continued to attract negative attention, Indiana Governor Evan Bayh ordered the troubled hospital closed. His decision promised to save the state millions of dollars and won plaudits from many, but not all, mental health advocates. Even as the last patients left in 1994, some families continued to challenge the wisdom of eliminating Indiana's only large urban mental hospital, but to no effect.

Colonial surgeon Patrick Hill (1794-1852): unacknowledged pioneer of Australian mental healthcare.

Despite making a substantial contribution to the development of mental health services in colonial Australia, until now the story of Dr Patrick Hill's (1794-1852) life has been overlooked by historians. This paper reviews primary sources including clinical notes, patient lists, letters, government documents and newspaper articles which reveal that Dr Hill was a dedicated physician who played a vital role in the development of Australian mental healthcare. He was held in such esteem that by the time of his sudden death in 1852 he had been elevated to the most senior medical office in New South Wales. Dr Hill's career serves to exemplify how the local practice of individual colonial doctors helped build the reputation of medicine in the modern era.

Not just a one-man revolution: the multifaceted anti-asylum watershed in Italy.

The Italian psychiatric 'revolution' is the story of a range of flexible, changing formulas, exposed to many 'contaminations'. Historical reconstructions have remained anchored to the lure of a founding myth and an eponymous hero. This essay aims to shed light on the multi-faceted concept of the Italian 'moral management revolution'. We especially focus on: the circumstances which triggered the innovation in its various form; the 'prototypes' available in other countries which have been variously recombined in the different local contexts; the 'special path' of action strategies which has driven the change towards radical closure of the asylums; and the cause-effect relationship between the above 'special path' and several aspects of the current state of deadlock.