Parnassia Psycho-Medisch Centrum, Monsterseweg 83, 2553 RJ, The Hague, The Netherlands
In his editorial on care in the community, Julian Leff (2001) describes processes comparable with those in The Netherlands, resulting in a call for increasing restrictive mental health legislation enacted by governments pandering to public misperceptions. This may be an indication that this process is more universal and not restricted to the situation in the UK. A few points may lead to more perceived failure if not addressed.
Dr Leff states that there is substantial evidence of considerable success... of the 130 psychiatric hospitals... in 1975, only 14 remain open, with fewer than 200 patients in each. Does this imply that it would have been a failure if it were 25 hospitals with 300 patients each? Closing hospitals should not be a goal as such, but a means to provide better services to patients. That a new generation of psychiatrists not only have never worked in a psychiatric hospital but have never seen one! may not be such a desired development. In the coming decades in-patient facilities will still be needed and the number of them may fluctuate because of new treatment modalities and the capacity of society to harbour patients. An increase or decrease should not be an indicator of success or failure at all.
The invisibility of a community service as grounds for perceived failure is interesting in relation to the statement that the architectural presence of the asylums has been replaced by an apparent absence. Were many asylums not tucked away at the outskirts of the city, if not further away? Mental health care should make itself, and its diversity of services, more visible. Could it be that professionals, patients and relatives have a somewhat defensive stance regarding the public and the media? In The Hague after the merger in 1999 of all psychiatric hospitals, community mental health organisations and addiction organisations, posters were put on trams and bus stops leading to a high visibility, which was well perceived.
Would a comprehensive community psychiatric service catering to all the needs of the catchment area population enhance the perception of success? In The Netherlands in recent years this development has started in some areas owing to large-scale mergers of mental health organisations. This has lead to a disappearance of administrative and financial boundaries between in-, out- and day-care patient services. In The Hague there are indications that the needs of patients, family, general practitioners and police are better identified and addressed, leading to a visible profile and higher perceived success.
If we want to know what our targets are in a public relations job of this kind, we are at the brink of a more fundamental shift of defining and positioning the concept of (community) mental health. Who can identify him or herself with a psychiatric patient? Are there not fundamental differences between a patient with schizophrenia, agoraphobia or bipolar disorder? In The Netherlands generalisation and stereotyping lead to the situation that the acts of one person with an addiction and personality disorder may damage the positive image of mental health in general for a certain period.
Community-oriented care is a success for a subgroup of patients with psychiatric disorders. Perceived failure in one area should not lead to a situation that the whole of mental health services, including care in the community, is perceived as a failure.
REFERENCES
Leff, J. (2001) Why is care in the community
perceived as a failure? British Journal of Psychiatry,
179,
381-383.
Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK
Regrettably, Dr Hoencamp has misinterpreted a number of phrases in my editorial. Rather than calling for increasingly restrictive legislation, I was warning the reader against this alarming consequence of public and governmental misperceptions of care in the community. On another point, I certainly did not mean to imply that closing psychiatric hospitals is itself an indication of a successful policy. The evidence of success to which I was referring consists of the growing body of research showing that the quality of life of discharged long-stay patients is improved by relocation in community homes (e.g. Leff & Trieman, 2000). Dr Hoencamp is of course right that in-patient facilities will continue to be needed, but there is no reason for them to be located in the outdated structures of the psychiatric hospitals. There are undoubtedly problems with admission wards in district general hospitals, but these can be remedied by improved architectural design and the provision of alternatives such as acute day hospitals (Creed et al, 1990).
Although many asylums were deliberately built outside of towns, urban expansion brought them within the ambit of residential areas. Even those that remained remote, engendered in the public mind the image of life-long incarceration. I agree with Dr Hoencamp that more should be done to publicise community mental health services. We should be proud of what has been achieved and promote a high visibility. He raises the issue of the diversity of psychiatric disorders and the difficulty the public and the media have in distinguishing them. This dilemma faces any organisation attempting to change public attitudes towards people with mental illness and the services they need. The Royal College of Psychiatrists' campaign Changing Minds: Every Family in the Land addresses a wide range of psychiatric disorders, while the World Psychiatric Association's Global Campaign against the Stigma of Schizophrenia focuses on that one condition. Hopefully the results of these programmes will indicate which is the more effective strategy. However, early results from the World Psychiatric Association campaign indicate that education aimed at teenagers in schools produces the most positive change in attitudes. A good strategy would seem to be the inclusion in the school curriculum of information about the diversity of disorders and treatment modalities in psychiatry.
REFERENCES
Leff, J. & Trieman, N. (2000) Long-stay
patients discharged from psychiatric hospitals. Social and clinical outcomes
after five years in the community. The TAPS Project 46. British
Journal of Psychiatry, 176,
217-223.
Creed, F. H., Black, D. & Anthony, P. (1990) Randomised controlled trial comparing day and inpatient psychiatric treatment. BMJ, 300, 1033-1037.[Medline]
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