In 1953 the newly created World Health Organization (WHO) defined the health as the complete state of bio-psycho-social well-being, and not only as the absence of disease. This has to do with the policies of the Welfare State (in fact, the expression appears in the definition) that were taking place throughout the world. At the same time, WHO proposed a psychiatric reform that would transform the asylum into therapeutic communities.
The humanization of mental health
This meant the passage of Mental Medicine, dominated by alien medicine or Psychiatry, towards Mental Health that included two characteristics:
- the loss of power of psychiatry as a totalizing discipline; Y
- the creation of preventive-assistance devices.
From here, the asylum devices that had expanded in the nineteenth century and the biological-based treatments that were applied until then (Galende, 1997) begin to be questioned.
Great Britain, the first step
In 1959 Britain became one of the first countries to make a reform by approving the Mental Health Act (revised in 1983). Is promotes the rights of patients and the reduction of hospitalizations. From 1962 the main Psychiatric Hospitals were closed and small Mental Health units were created in the General Hospitals. The Act created control agencies for compliance, mental health services, Health Councils with the participation of the community, outpatient networks, day hospitals and home care systems. In 1962, the National Institute of Mental Health was created by a provision of the British Ministry of Health to coordinate actions in the area and carry out strategic planning at local levels. This planning was carried out jointly in different instances: 1) local health authorities; 2) local Social Service authorities; 3) voluntary services (through social organizations); 4) the private sector; and 5) Local Health Councils. Mental health coverage at the national level became possible thanks to this planning, as well as strong state funding (Galende, 1997).
United States joins the reform
Similar policies were applied in other countries. In the United States, the Kennedy Law that created the Federal Community Psychiatry Program was passed in 1963. In France - cradle of the asylum - a reform of the sector was carried out between 1965 and 1968 promoted by the Patriotic Front that had its center in Saint Alban (Stolkiner and Solitario, 2007).
Italy and social inclusion
In 1978, the year in which the Declaration of Alma Ata was approved for universal access to Primary Health Care (PHC), began in Italy a psychiatric reform promoted by Franco Basaglia and Franco Rotelli which had its center in the municipality of Trieste. After the closure of the insane asylum, the budget and the personnel who worked in them were allocated for the home and community care of the people previously locked up and those who had never received attention. Rotelli (2014) considers that the asylum is the “zero point” of social exchange, so intermediate mechanisms must be created that allow social inclusion of the people that this institution helped to “become disabled”. For this psychiatrist, mental illness is not something organic or psychic that is in the person, but something that includes the entire social body, so attention must be community. In 1981, National Law 180 was passed that modified psychiatric care in the country: creation of psychiatric beds in general hospitals, non-hospital residential centers with full-time or part-time staff, and non-residential outpatient centers (day centers, dispensaries). In the following ten years the number of people admitted to psychiatric hospitals was reduced by 53%. At the same time there was an increase in the phenomenon of “Revolving door” (people discharged from entering again) in areas that lacked well-organized services. Although the Italian experience was an example worldwide, in the following decades there were great setbacks (WHO, 2001).
Uganda, still in prisons
In Uganda, mental health services were decentralized in the 1960s, creating Departments of Mental Health in Regional Reference Hospitals. Nevertheless, those departments looked like prisons, they were attended only by psychiatry staffThere was a lack of supplies (especially medicines) and there were no funds for community activities. In addition, the population was not informed about psychic disorders and up to 80% of the people who suffered from them attended healers rather than hospital services. In 1996, the National Ministry of Health together with the WHO began a program to integrate mental health into Primary Health Care. Community care levels were implemented, health agents were trained to recognize psychic and neurological pathologies, referrals increased and links were created with other programs such as HIV-AIDS. Later, a Mental Health Law was passed and the number of beds in the National Psychiatric Hospital began to be reduced when attention was transferred to the Reference Hospitals (WHO, 2001).
Argentina and the new home care
In Argentina, mental health reforms were implemented in the provinces of Rio Negro and San Luis. In the first one a policy of reduction of hospitalizations, the creation of Mental Health Services in General Hospitals, the home care through health workers trained between public employees and the participation of families and the community. The approval in 1992 of Law No. 2440 on Health and Social Promotion for People with Mental Suffering, which prohibits mental health and neuropsychiatric disorders, as well as any treatment whose sole purpose is confinement and seclusion. Further, torture techniques such as electroshock are prohibited and the maintenance of social ties is promoted for people who must be admitted (Government of Rio Negro, 1993). In San Luis there was a "Process of Institutional Transformation" which was centered at the Psychiatric Hospital of the provincial capital. Since the end of 1993 and under the direction of Dr. Jorge Luis Pellegrini, two specific measures were taken: not to admit the chronified (turning the hospital into acute) and take inmates to the street (for its reconnection with society). Through programs, such as “Substitute Families,” people admitted for years or decades regained their freedom and were able to have outpatient care. In 2001 the Psychiatric was transformed into a Mental Health Hospital and in 2004 it began to function as a School Hospital to train health effectors. In 2006 the provincial legislature passed the Law of Deinstitutionalization (Pellegrini, 1998, 2011, 2011b). The reforms of Rio Negro and San Luis were antecedents of the National Mental Health Law No. 26,657 approved by the Argentine Congress in 2010.
Australia and government aid
In Australia, the federal government and the Ministries of Health of the different States adopted in 1992 the first "National Mental Health Strategy". The first five-year plan was applied in the period 1993-1998, and meant a 30% increase in the mental health budget and an 87% increase for community-based treatments. As in other countries, hospitalizations were reduced in psychiatric hospitals and services were created in general hospitals, while funds were allocated to help organizations of people with disabilities (WHO, 2001).
Asian countries, with help from the community
Community-based treatments were also applied in Asian countries such as India, Cambodia and the Islamic Republic of Iran (WHO, 2001).
A deficit observed in all these reforms is that they focused mainly on the urban environment, giving little attention to the inhabitants of rural habitats. An exception was the United Republic of Tanzania, which implemented an intersectoral response to provide mental health assistance to fishermen, farmers and artisans. It consisted of a joint work between health workers, nurses, psychiatry professionals and local healers who are usually attended by the rural population. The idea was achieve cooperation between the traditional sector and the "scientific" medicine sector. The healers were also trained to recognize different mental pathologies (WHO, 2001).
Inclusive medicine in the twentieth century
The mental health reforms of the twentieth century that occurred in different countries of the world are based on different principles than those supported by the Alienist Medicine of the nineteenth century. In the first place, it does not speak of “Mentally Ill” which would give a static character but of “People with Mental Suffering” or “People who suffer from Psychotic Disorders” (Declaration of Caracas, 1990) that has a dynamic character. Secondly, it is not monodisciplinary but works with the idea of Interdisciplinary Mental Health Teams. Thirdly, it is not based on only biological-based treatments but on a multiplicity of social, psychoanalytic, anthropological, community-based treatments, etc. Finally, it is not based on the idea of the danger of the person with mental suffering but of their vulnerability, so that hospitalization is justified only in case of certain and imminent risk (Galende, 1997).
This article is a fragment of the book: Brief History of Persons with Disabilities: from oppression to the struggle for their rights, Mauritius, Spanish Academic Editions, OmniScriptum, 2018.
- Galende, Emiliano; (1997) Of an Uncertain Horizon, Buenos Aires, Editorial Place.
- Rio Negro Government; (1993) Demanicomialization in Rio Negro. Law 2440 on Health and Social Promotion of Persons with Mental Suffering, Viedma, Provincial Council of Public Health.
- WHO; (2001) Report on world health, Geneva, Atlas Project.
- Pellegrini, Jorge Luis; (1998) Five years of struggle for institutional transformation, San Luis, Government of San Luis.
- Pellegrini, Jorge Luis; (2011) When the asylum is not, San Luis, Payné.
- Pellegrini, Jorge Luis; (2011b) Live without confinements San Luis, Payné.
- Rotelli, Frank; (2014) Live without asylum. Trieste's experience, Buenos Aires, Topia.
Stolkiner, Alice and Lonely, Romina; (2007) "Primary health care and mental health: the articulation between two utopias", in: Maceira, Daniel (comp.); Primary Health Care: artRelated tests
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