Hong Kong Journal of Psychiatry (1996) 6 (1), 38-44

REVIEW ARTICLE

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INTRODUCTION

De-institutionalization and community care are the most influential movements in the mental health field within these thirty years (Thomicroft & ebbington, 1989; Brown, 1975;

Archer & Gruenberg, 1982; Wing, 1981; Bachrach, 1976 & 1978, Hafner & Heidner,1989; Bennett, 1979). This article is a historical review and critics about the community care movement in the U.K. and the U.S.A.. Community care in the mental health field can be defined as multi-faceted and multidisciplinary, involving not only those responsible for providing statutory health and social services but also the family, voluntary bodies and in fact, the whole community itself (D.H.S.S., 1978).

HISTORICAL REVIEW

The development of community care movements in the U.K. the U.S.A. can be roughly divided into three stages:

1. the pre-community care era
2. from de-institutionalization to community care
3. community care or re-institutionalization

THE PRE-COMMUNITY CARE ERA

Strictly speaking, the foetus of community care occurred long before the de-institutionalization movement. In 1200, community care for the mentally ill was evident in Geheel, Belgium, when people were placed in families for mental health care. In the U.K., the Mental Aftercare Association was founded in 1879 (Willams & Lancaster, 1988). The work of the Association was initiated on a comparatively small scale with focuses on residential and personal care of very limited amount of ex-patients (Hawkins, 1879). Apart from the Aftercare Association, three more voluntary associations had operated on a national scale to promote the community care for the mental outpatients. They were the Central Association for Mental Welfare, National Council for Mental Hygiene, and the Child Guidance Council. The Feversham Committee in 1939 suggested amalgamation of these four voluntary associations to take part in community care of mental outpatients (Jones, 1972). Furthermore, the first general hospital clinic for psychiatric outpatients was established at St Thomas Hospital in about 1890. The number of outpatient clinics grew drastically after the World War I. Later, the Mental Treatment Act 1930 gave local authorities the power to arrange out-patients. There was a drastic increase in the number of outpatient clinics with at least 216 outpatient clinics by 1942 (Blacker, 1946; Board of Control, 1930; Gibson, 1963; Hurst, 1949).

In the United States, concepts and practices of community care was actually originated from Cliff Beers' Book, A Mind That Found Itself (Beers, 1908), and his establishment of the National Association of Mental Hygiene in 1909. Following this was the mental hygiene movement stressing early detection, and prevention of mental illness (Archer & Greenberg, 1982).

This movement stimulated the establishment of child guidance clinics for maladjusted children instead of mental hospitals. The most significant outcome of pioneering in child guidance was the stimulus it gave to mental health research. It also stimulated the establishment of adult outpatient clinics after World War I (Felix, 1957).

Generally speaking, the community care movement in the U.S.A. and in the U.K. were nourished by the pioneering work of voluntary organizations and the establishment of outpatient clinics. Gradually, such services were recognized and legalized by the government after 1950.

FROM DE-INSTITUTIONALIZATION TO COMMUNITY CARE

In the Nineteenth Century, all forms of disorders were admitted to the infirmaries or workhouses (Mayou, 1989). Of course, conditions in these workhouses and the infirmary ward in hospital was terrible and awful. A special committee of the Huddersfield Guardians reported in 1857 that the lack of classification of those in hospital wards led to a deplorable mixture of cases, child and adult physical and mental disorder, in " utterly unfit " accommodation (Maryland, 1987). At the end of 1930s, mental hospitals were overcrowded and understaffed (Webster, 1988).

In the U.S.A. at first almost every northeastern and midwestern state supported an asylum by 1850. Nevertheless, as the asylums were over congested with too many mental patients, the conditions of the asylum were intolerable (Rothman, 1981). In 1930s, someone admitted to hospital in the United States and the United Kingdom and given a diagnosis of schizophrenic had a one-in-three-chance of being discharged at all except by death (Wing, 1981).

The aversive conditions of the asylum finally caught the attention of the Parliament members and the general public in 1950s (Jones, 1972). Then, there was a strong trend of criticising the aversive effect of institutionalization in asylums by social scientists and the health professionals. Following this, it is a strong de-institutionalization movement simply by discharging mental patients into the community (Goffman, 1961; Barton, 1959; Wing & Brown, 1970; Tooth & Brook, 1961; Scull, 1979; Levine, 1981; Busfield, 1986; Thronicroft, 1988,

Mechanic, 1986; Bassuk & Gerson, 1978). As the de-institutionalization movement prevailed, the number of psychiatric outpatients in the community increased drastically. It dramatically evoked the development of the dominating community care movement from 1960s to 1980s in the psychiatric outpatients service. Apart from the de-institution-alization movement, the intervention of psychoactive drugs also speeded up the community care movement. The chlorpro-mazine group of drugs popularly called tranquilizers were developed in 1952. The tranquillizing therapeutic effects of such drugs allowed the patients to remain out of the hospital and function adequately in the community (Davis, 1980).

In 1953, the third Expert Committee on Mental Health of the World Health Organization produced a new report which offered a new model for the development of the Mental Health Service. This model suggested a variety of services including inpatient, outpatient, day care domiciliary care, hostel and other related community services. The hospital became only one alternative in caring mental outpatients (World Health Organization, 1953). The first reaction to the new model of practice and the new psychotropic drugs are open door policy with more open ward, parole system, outings and open days in the mental hospital. The second reaction was the new establishment of day hospital, introduction of industrial therapy, and day patients to ensure that the patients could maintain normal contacts with the society (National Association for Mental Health, 1957). In the same way, to humanize the treatment environment, the therapeutic community system was introduced by T.F. Main in 1946. Maxwell Jones (1968) further elaborated the concept of therapeutic community in terms of permissiveness, communalism, democratization, and active rehabilitation in facilitating the patients' potential for recovery.

In 1959, the new Mental Health Act legalized informal admission of mental patients and it approved the establishment of the Mental Health Review Tribunal. By these two measures, unnecessary hospitalization was prevented and they facilitated mental patients for a better contact with the community. In 1962, Powell policy proposed community care and comprehensive district hospital for the mental patients. Following this trend there were the closing of large mental hospital, the integration of psychiatry with general medicine, the shift to the local authority of the responsibility for residential and social care and further development of community care oriented treatment and rehabilitation services in forms of day hospital, outpatient clinics, hostels, and social aftercare services in the 1960s and 1970s (Jones, 1972; D.H.S.S., 1971 & 1975). In 1975, the paper for the Better Services for the Mentally Ill was published by the government. In this paper, the needs of the mentally ill were comprehensively defined in terms of prevention of relapse and mental hygiene, early recognition, assessment, clinical treatment, social rehabilitation, help from the family, accommodation, and treatment (D.H.S.S., 1975). The pattern of services suggested in this paper was a comprehensive network of health and social services facilities in each district in forms of general hospital psychiatric unit, day care, social clubs, residential care, vocational training, sheltered employment and long term care services for the chronic, elderly, and homeless mentally ill. Community care services were also widened to serve the children and adolescents with mental problems as well as alcoholics, and drug addicts. Finally, the coordination and manpower training of the community care service were received proper attention in this paper. No doubt, this policy paper reflected that community care movement reached its peak of recognition and implementation in the Britain. Its rationale and services models were still influential to present psychiatric services in Britain. Similar ideologies were echoed by the Royal College of Psychiatrists. In 1980, an important paper 'Psychiatric Rehabilitation in the 1980s' was published by the Royal College of Psychiatrists on the request of the Department of Social Security. In this report, the rehabilitation needs of the adult chronic psychiatric patient were highlighted. Better training of psychiatric staff , coordination of psychiatric services were also suggested (Royal College of Psychiatrist, 1980).

Parallel to the development in the U.K., community care movement in the United States developed quickly after the World War II and flourished in 1970s (Archer & Greenberg, 1982). The National Mental Health Act of 1946 was passed in 1947. This Act created the National Institute of Mental Health to provide research and training grants to develop communitybased psychiatric services (Felix, 1946). The Mental Health Study Act was passed. It financed the Joint Commission on Mental Illness and Health to analyze and evaluate the needs and resources of the mentally ill in the United States and to make recommendations for a national mental health program (Joint Commission on Mental Illness and Health, 1961). The Commission produced its report in 1961, highlighting the community care placements for patients of open mental hospital as well as early detection and treatment (Joint Commission on Mental Illness and Health, 1961). The Community Mental Health Act was passed in 1963. It called for the construction of mental health centres in each catchment area. It defined a catchment area as a geographic region with a population of 75,000 to 200,000 people ( Brown, 1964 &

Langsley, 1980). In 1965, the Public Law 89-105 provided federal funds for the staffing of those centres. These centres had five basic types of services: inpatient treatment, emergency services, partial hospitalization, outpatient services and consultation-education. In 1968, the Public Law 90-574 added alcoholism and drug abuse to the mental health concerns (Langsley, 1980). In the 1960s, many states passed legislation that removed the power of the courts to issue involuntary commitment so to prevent inappropriate admission and detention. In 1975, the Public Law 94-63 was passed. In this Act, Congress recognized the success of the community care movement in mental health services and sanctioned the federal responsibility for the treatment and prevention of mental disorder. Apart from the five basic services, seven more services were added. They were: services for children, services for the aged, follow-up services for patients formerly in institutions, screening before admission to state hospital, alcoholism services, drug abuse services and transitional housing services (Langsley, 1980).

COMMUNITY CARE OR RE­ INSTITUTIONALIZATION

In 1980s, the practice of community care was under critical review by professionals and policy makers in the U.K.. In 1986, two important papers, 'Making a Reality of Community Care' and 'Community Care: An Agenda for Action' was published by the government. In these two reports, the gloomy and idealistic picture of community care for the mentally ill and other disabled groups was critically reviewed. To implement community care, it needed to add more resources, increase state control and management, and enhance contribution from voluntary sectors and the general community (Griffiths, 1986; Audit Commission, 1986). Later, another important paper 'Caring for People: Community Care in the Next Decade and Beyond' was presented in the Parliament. In this report, the defects of de-institutionalization without the support of adequate community care services was fully recognised. Further increase in funding of social care and hospital care for the psychiatric patients were recommended (Department of Health and Social Security, 1989).

Similarly, in the U.S.A., the practice of community care was under criticism. In 1984 to 1985, a Delphi process studies found out that 42 states had no consensus in the support of chronic mental patients being treated outside institutions (James, 1987:447). Also, both academics and professionals began to challenge the possibilities of community care in taking care of the chronic and homeless mental ex-patients (Elphers, 1987; Lamb & Shaner, 1993: & Okin, 1985). Furthermore, Langsely (1985) pointed out there had been a number of problems in the implementation of the community mental health centres. They were: '-neglect of the mentally ill; problems in accessibility and availability of treatment; problems in governance; fiscal problems; staff problems; catchment area problems; overenthusiasm for prevention; health vs social service models; and second class services' (Langsely, 1985)

In short, the community care movement in the U.K. and in the U.S.A. originated long before the de-institutionalization. After 1950s, the de-institutionalization movement and the invention of psychotropic drugs strengthened the growth of community care movement in the U.K. and in the U.S.A. In the 1960s and 1970s, this movement became the dominant trend in the mental health service. In the 1980s and 1990s. there were severe criticism towards the community care movements. This criticism can be summed up into the following four areas of concern which will be discussed in next session:

1. Idealistic Assumptions of Community Care
2. Vague and Unclear Definition of Community
3. The Under-Development of Informal Community Care
4. The Under-Estimation of the Protective and Custodial Functions of Mental Hospitals.

DISCUSSION

IDEALISTIC ASSUMPTIONS OF COMMUNITY CARE

Hawks (1975) had critically assessed the underlying assumptions of the community care movement, which can be summarized as follows :

• community is therapeutic and caring in natures;
• chronic and long term patients can be discharged from the hospital easily without adverse consequences;
• mental illness can only be understood and treated in its social context;
• family and relative can take up the burden of the discharged patients;
• community care programmes and services can successfully treat chronic disability present in the community or prevent its development in the first instance; and
• community care is a moral enterprise with humanitarian ground to reject institutional care.

Hawks commented that all these assumptions of community care was actually a myth rather than a reality in caring the mental patients and outpatients in the community.

In the same way. Bachrach (1978) echoed such views and challenged the possibilities of the community in fulfilling the ideologies and functions of community care. Both Hawks and Bachrach assume that good community care was not realistic. Outcome studies reviewed that many mental patients were left uncared within the community (Braun, et.al, 1981). The service programs and the social agencies rendering such services can not replace the role and functions of institutional care especially in caring the homeless and chronic mental patients. Furthermore, community may be harmful and rejecting to the mental patients and outpatients. Mental patients are discharged into the community without proper care. Their conditions may be even worse than those patients in a good and caring hospital.

VAGUE & UNCLEAR DEFINITION OF COMMUNITY

In the community care movement, the definitions of community were vague and unclear. The 'community' where the discharged patients facing was only vague and unclear. It might be a geographical area, a district or a region where the ex-patients lived. It might be a functional group such as the families and relatives of the ex-patients or the general public. The most important misunderstanding is what Hawks (1975) and Bachrach (1976) pointed out: it might only mean 'community based' rather than the actual community itself. The interactive natures of the community were left out in the process of treatment and rehabilitation.

The community, as I now see it, may be defined as patterned interactions within a domain of individuals seeking to achieve security and physical safety, to derive support at times of stress, and to gain selfhood and significance throughout the life cycle' (Klein, 1968).

UNDER-DEVELOPMENT OF INFORMAL COMMUNITY CARE

In the concept of community care, Bayley (1973) and Bulmer (1987) had distinguished two types of community care. They were ' care in ' and ' care by ' the community. ' Care in ' the community means care provided in the community. It refers to formal care in forms of residential homes, hostels, outpatient clinics, small or day hospitals, community mental health centres, outreaching home help. Such services are provided by qualified paid staff in well funded organizations and agencies. 'Care by ' the community implies the care provided by informal or natural networks such as: families, friends and neighbours in individual and informal clubs and association bases. Such service providers are merely voluntary and in natural homely settings (Bulmer, 1987; Bayley, 1973). A careful examination of the community care movement in the U.K. and the U.S.A reviewed that it only focused on the formal community care for mental ex-patients. Actually, informal community care for the mentally ill was evident in Ghee!, Belgium in 1200, when people were placed in families for mental health centre

(Williams & Lancaster, 1988), but it did not received enough attention in the whole process of community care movements. As what Bulmer (1987) pointed out, 'the failure to think through the implication for informal care of the deinstitutionalization of the mentally ill and the mental handicapped................. There has been very little attention paid to the implications of the policy for informal care and carers, though the policy's impact is considerable.

It is crystal clear that the social interaction within a community described by Klein were not properly considered by the both the policy makers and the practitioners in the process of community care. They simply thought that the community was another type of 'dumping ground' for the ex-patients. Actually all these interactive natures of the community existed in various forms of patterns and communication among the members of the community. Kelin further elaborated that: 'the community establishes pattern for such interactions, which rest on differentiation of roles, allocation of social status, and the provision of acceptable means of social mobility. It appears that the way of handling such functions have a lot of psychological implications to the well being of the members of the community. Such functions and interaction patterns determine the handling of deviance, developing identity and meeting individual member's needs in various ways' (Kelin, 1968).

Proper community care should be exercised well within these interaction patterns so that the mental ex-patients can be tuned back and accepted within the community. Nevertheless, the community care movement in the U.K. and the U.S.A. was only a movement of transferring the patients from institutions to mini and decentralized 'institutional like' community mental health care centres or outpatients clinics. The discharged patients are not actually integrating back into the communication channels and interactive patterns of the community. The actual subsystems and dynamics of the community (Kelin, 1968) were untouched within the vague and unclear definition of the community care. · 1

In Bulmer's view, the failure of the community care movements is mainly due to the under-development of the informal community care. The criticism by Hawks (1975) and Bachrach (1978) on the idealistic assumption of community care was actually due to the fact that the community has not be prepared or developed to accept the return of the mental ex-patients from the institutions. Community care should not only be interpreted as transferring institutional care into formal community care or decentralizing the medical oriented hospital care into small units of mental health related services. It should also mean the development of natural support systems, including: neighbours, family and friends by offering spontaneous informal support and acceptance for mental patients. In that sense, one should neither have the myth of assuming that every community is good enough to fulfil all the requirements of providing good community care nor have a pessimistic view that all communities are harmful to the care and rehabilitation of the mental patients. Rather, one should put more effort in estimating and developing the caring potentials of the community by smoothing the coordination of formal services, educating the general public to accept the mentally ill, and supporting the family and friend to care the mentally ill in a more normalized environment. Strictly speaking, the comm-unity care movement in the U.K. and in the U.S.A was only a development of formal community care. Informal community care have not been considered and developed even during the peak of community care in the 1970s.

THE UNDER-ESTIMATION OF THE PROTECTIVE AND CUSTODIAL FUNCTIONS OF MENTAL HOSPITALS

Community care and institutional care for the mentally ill, especially good institutional care should not be interpreted as mutually exclusive or antagonistic to each other. In actual practice, the protective and custodial function of small sized mental hospital can never be underestimated. Thornicroft and Bebbington (1989) had an assessment of the effectiveness of the transferal of manifest and latent functions from the psychiatric hospital to the formal community services.

MANIFEST FUNCTIONS OF PSYCHIATRIC HOSPITALS

• Active treatment for short to intermediate stay patients
• Custody for long-stay patients
• Physical assessment and treatment
• Protection of the patients from exploitation
• Respite for family
• Haven or Asylum for patient
• Research and Training centre
• Provision of day and outpatient services
• Secure provision for involuntary and aggressive patients
• Occupation and Vocational rehabilitation
• Shelter, nutrition, basic income and clothing (Thornicroft and Bebbington, 1989:743)

In actual practice, the above protective and custodial function of the hospital can never be fully replaced by nonmedical base formal or informal community care services, especially in dealing with psychiatric emergencies. Furthermore, as what Hawks (1975) pointed out severe and chronic mental patients, to certain extent, required good and humane institutional care (Hawks, 1975). The failure of the community care movements is partly due to the assumption of total elimination of the 'evils' of the large institutions and neglecting the protective and custodial function of good and humane middle sized or mini-sized institutions for mental patients.

CONCLUSION

As a conclusion, this paper is a historical review about the community care movements in the care of the mentally ill in the U.S.A. and in the U.K.. The development of this movements was criticised to be unsuccessful because of idealistic assumption of the community care, the vague and unclear definition of community, the under-development of informal community care and the under-estimation of the protective and custodial function of mental hospitals.

INTEGRATION OF FORMAL AND INFORMAL COMMUNITY CARE

In fact, to have a good and effective community care for the mental patients and mental outpatients, it is better to have the following clarifications in the assumptions and philosophy of community care :

1) Both formal community care and informal community care should be developed
2) Formal community care and informal community care are not mutually exclusive to each other. They are, in fact, complementary and supporting one another in any one of the following ways :

1. Formal community care service agencies allocate professional and resources in developing the informal support networks, such as, relatives, friends, neighbours, and volunteers, so that mental patients can be treat and rehabilitated in a more integrated, normalized and natural environment.
2. Informal community care networks once being strengthened, can actually alleviate the loading of the formal community care in caring the mental patients and Prevention of relapse is more substantial in stable and supportive natural networks of the mental patients and outpatients. They are, if properly developed, are actually create more effective and long lasting resources for the formal community care.
3. Formal community care in terms of good and humane small mental hospitals, residential hostels and community mental health centres, no doubt, can provide good support, shelter and treatment for those mental patients and outpatients with poor and rejecting relatives, friends, neighbours and However, these services should not be aimed as the final end of the mental patients. Rather, they should be aimed as preparing patients to rebuild better social support so as to return back to the community.
4. Good informal community care in forms of mutual aid groups and relative and friends groups can provide a role in advocating the rights of the mental patients and outpatients. They should work hand in hand with those professional formal community care services.

IMPLICATIONS TO COMMUNITY CARE OF MENTAL PATIENTS IN HONG KONG

Generally speaking, the historical development of psychiatric services in Hong Kong has not been affected by the de-institutionalization movement in the western countries. Psychiatric services in Hong Kong is a mixture of large institutional care and community based rehabilitation services. Without the attack of the de-institutionalization movement, the protective and custodial function of mental hospitals in Hong Kong are fully exercised. However, due to a drastic increase in the number of mental patients and a shortage of manpower, conditions in mental hospitals in Hong Kong are unsatisfactory. Many psychiatric wards are still overcrowded and congested. Also, a close look of the mental health policy in Hong Kong reviewed that the defects occurred in the above mentioned community care movement similarly exist in Hong Kong. Though with the terminologies of 'full participation' 'equal opportunities' (Hong Kong Government, 1992 & 1995), the definition of community care for and rehabilitation for mental patients is vague and unrealistic. Disregard the public stigmatization of the mentally ill, the policy makers still assume communities are caring and accepting for the mental patients. They simply assume 'full participation' and 'equal opportunities' can be fully exercised by the mental patients within the community. On the other hand, many service providers simply assume the community is totally rejecting of mental patients. Thus, the best way to implement community care is simply to avoid contact of community by keeping the mental patients within the four walls of formal community care services !il{e half way houses and sheltered workshops, day care centre or long care homes. Secondly, informal community care in forms of mutual aid groups, family support, social support networks and aftercare for mental patients, though being implemented by many agencies, had not been recognised and financed by the government (Ma, 1992) To improve the community care of mental patients in Hong Kong, the following suggestions are worth noting by policy makers and service providers in shaping the future directions of the mental health policy:

1. It is better for Hong Kong Government to input more resources in improving the overcrowding situation and environment in mental hospitals. If possible, more mini-sized or middle size mental hospitals should be built to ease the congesting situations in the present mental hospitals. Good community care of mental patients should start from a good and humane hospital mileu and environment.
2. The policy makers should recognise and develop informal community care work, such as personal aftercare work, mutual aid group, social support network, family support for the mental patients. Only with proper development of such natural support systems, mental patients can actually integrated back into the community and lessen the overall burden to the mental hospitals and formal community care services.
3. Instead of assuming the community is either caring or totally rejecting of mental patients, it is better for the government and the service providers to develop the 'caring' spirit of the mental patients. Community education is necessary but not sufficient in building a caring community. Community members can not be caring simply by educational programme. A caring community can actually developed by continuous positive social interaction among mental patients and community Community development programmes should be financed and implemented to enhance such interaction. For instance, spontaneous constructive interaction between good members in the community and mental patients with good prognosis in form of joint volunteering work to serve the community is the first step to re-establish the social integration and normalization of mental patients. Service providers in formal community care services and mental hospitals should be keen in building an keeping good community networks to facilitate integration of their mental patients.

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Karn-shing Yip PhD, MSoc.Admin. MAASW Assistant Professor, Department of Applied Social Studies, Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong.