Can deinstitutionalisation work? Mental health reform from 1993 to 1998 in Victoria, Australia.

ABSTRACT

From 1993 to 1998, mental health services underwent a major transformation in Victoria, Australia. The changes aimed to create a community-oriented service system under general health, instead of one based on psychiatric institutions. Community treatment was to be the first option, with hospitalisation as a backup. State psychiatric institutions were closed, and replaced by new area-based mental health services, providing local inpatient, residential and community-based care. This included mobile extended hours services, available seven days per week.

The article examines the rationale and nature of the changes. It argues that Victoria's reforms largely avoided problems usually attributed to deinstitutionalisation. This was because alternative services that were comprehensive and locally accessible were established before institutions were closed. Start-up funding from federal and state governments helped this transition, with institutional savings reinvested in new services. By 1998, the changes were substantial, although institutional practices were not transformed as thoroughly as the structures.

KEY WORDS

psychiatric deinstitutionalisation; mental health service reform; implementing mental health reform; community mental health care; mental health care in the community

Introduction

Deinstitutionalisation is a fraught topic in the mental health field. Few issues of mental health reform are so contentious. The term itself is open to different interpretations. To the lay person for instance, deinstitutionalisation means shutting down psychiatric institutions, thereby releasing inmates (assumed to be permanent residents) into the community, irrespective of whether follow-up care has been arranged. For reformers, deinstitutionalisation encompasses both the closure of state institutions and their replacement with a range of community-based alternative services, including residential and inpatient services as well as home treatment (Bachrach 1997:23; Hoult 1986).