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Mental institutions eroded, new supports needed: Deinstitutionalization has become a catastrophe for families
Schizophrenia Update, December 2002
According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, a delusion is "a false personal belief based on an incorrect inference about external reality."
Ruth Millar of Victoria knew all about delusions. Then, one night in 1998, her son drove a sword through her heart. Aaron Millar, who suffered from schizophrenia, had been living with his mother because she was unable to find satisfactory care for him. On the night of the homicide, Aaron was experiencing delusions and hearing voices warning him that his mother was about to harm the family.
Unfortunately, the Millars' sad tale is far from uncommon.
A six-month investigation conducted by the Windsor Star found that Canada's mental health system is on life support: The report noted deficiencies in institutional and emergency psychiatric care, in the availability of anti-psychotic medications and in provincial legislation aimed at coercing patients to take their medications.
The report also lamented the insufficient training provided to police officers who confront psychiatric patients, and it highlighted the deleterious effect of the violent mentally ill on the criminal justice system.
Many of the problems detailed in the Star's investigation can be traced to deinstitutionalization, the policy that favours treating patients in the community rather than in psychiatric hospitals.
Conceived in the 1950s, deinstitutionalization was a response to evidence that confinement in hospitals frequently exacerbates the condition of psychiatric patients because it separates the patients from their loved ones and from community support.
Provincial governments have embraced deinstitutionalization with a passion -- partly because the closing of hospitals can provide an economic windfall.
According to the Canadian Mental Health Association, demand for acute care psychiatric hospital beds in British Columbia has been steadily increasing. Yet the number of beds was unchanged from 1986 to 1996, and then dropped in the next four years from 717 to 680.
However, while governments are pursuing deinstitutionalization, the policy has come under increasing scrutiny. Critics argue that the policy is harmful to patients, their families and society at large.
As far as patients are concerned, deinstitutionalization has has proven to be just as bad, if not worse, than the ill it was meant to cure: civil commitment.
The policy arose as a reaction against the often brutal confinement of patients against their will. Yet deinstitutionalization has been implemented in identical fashion: While patients were once forced into psychiatric hospitals, they are now forced out, regardless of how ill or desocialized they have become.
And in all of this, the patients themselves are not asked what they want, thereby proving that there's a fine line between what we do for people and what we do to them.
As for family members, the Star's investigation says it all.
Deinstitutionalization has been a catastrophe for families, largely because governments have been aggressive about ushering people out the hospital doors, but passive about placing patients in the hands of competent caregivers. The end result, as the Millars' story vividly illustrates, is that the patients' family members become the primary, and in some cases, the only caregivers.
As the Star's report notes, family members are often assaulted and sometimes killed by their mentally ill relatives.
Although the families of patients may try their best to support their loved ones, they are usually lacking in both the expertise and facilities needed to help someone confronting a serious mental illness. Sometimes love is not all you need.
And when there is no love -- when patients have no parents or children or siblings who are willing and able to care for them, the streets and the penitentiaries become their homes. Patients who would have been confined in psychiatric hospitals in the halcyon pre-deinstitutionalization days are now languishing in jails.
The report ought to be taken as a call to action. The rationale behind deinstitutionalization -- that patients do better when they are cared for in a supportive and loving environment than when they are warehoused in an institution -- is solid enough. But all we have done is eliminate the warehousing. The community supports that were once understudies to the institutions have failed to take the stage and the lead.
If we are to care for the mentally ill and for their families and for ourselves, then we need to be just as aggressive at developing community psychiatric resources as we are at destroying the psychiatric edifices of yesteryear.
If we believe otherwise, then we are the ones experiencing delusions.