Search

In 1976 I wrote the first edition of Deinstitutionalization: An Analytical Revie-wandSociologicalPerspective(1), a monograph that sought to sort out and conceptualize the many issues related to implementing a new philosophy of patient care. Since then, deinstitutionalization in its various manifestations, including its relationship to homelessness among mentally ill persons, has remained my major academic focus. The problems I discussed in 1976 have not been fully resolved, and serious new issues have arisen (2). The fact that substantial benefits have also accrued to many patients does not diminish those problems. As deinstitutionalization has evolved, new concepts and practices associated with service delivery have emerged, and a growing literature continues to catalog and assess their impact. It might be said that the major purpose of this column, The Chronic Patient, is to provide a means for documenting and disseminating new patient care strategies and the concepts underlying them. Change has also affected the language associated with deinstitutionalization. Words like “outreach,”

Dr. Bacbrach's Introduction: In the current climate of service delivery, individual states have had to assume increasing responsibility for providing an array of services to meet the diverse needs of the chronic patient population. This issue's guest columnists comment on one state's efforts.

Deinstitutionalization has created a new type of patient--the new young chronic--who has received most or all of his treatment during brief hospital stays and through extended contact with outpatient community care programs. A one-year study of 119 new chronic patients entering treatment in New York City between 1977 and 1979 casts light on their living arrangements, use of mental health services, social functioning, criminal activity, suicide attempts, and symptomatology.

In a population of almost 1,100 patients in an urban hospital's aftercare program for the chronically mentally ill, 137 patients (12.5 per cent) were found to have nonpsychotic diagnoses. Patients with nonpsychotic diagnoses tended to be older at the first psychiatric contact, a preponderance were first-born or only children, and a higher percentage had been or were presently married. The therapist's possible role in the prevention of chronicity in nonpsychotic patients is discussed; therapists may contribute to the creation of chronic patients, the authors say, by fostering the emergence of increased dependency needs in patients who initially present with acute symptoms. The limitations of psychotherapeutic intervention must be stressed to psychotherapy students, and psychotherapy with nonpsychotic patients should be time-limited and focused on problem-solving.

To explore the concept of the young adult chronic patient as a distinct clinical entity, the author analyzed a sample of 134 chronic patients on six variables relating to style of interaction with service providers and on diagnostic and demographic variables. The results showed that the 105 younger chronic patients in the sample wEre more likely than the older patients to be male, to be referred to treatment for suicidal and homicidal gestures and ideation, to have a diagnosis of personality disorder, and to be overrepresented in the treatment population. The author believes the combination of these factors helps create disproportionately high visibility for young adult chronic patients and requires special provisions for their engagement in treatment.

The emergence oftbe young adult chronic patient, and the attendant perception that deinstitutionalization has failed, may be viewed as the inevitable result of the success of deinstitutionalization. Deinstitutionalization gave freedom to the mentally ill, but in doing so it left patients free to struggle on their own. The deinstitutionalization ideology failed to predict the difficult clinical reality that most patients do not readily choose the identity of chronic mental patient and are reluctant to make use of available treatment programs. The author presents the key principles of a new post institutional ideology that focuses on helping patients attain the best possible adaptation to their illness regardless of the setting in which they are treated. He hopes the ideology will infuse new hope and clinical expertise into work with people with chronic mental illness.

The chronic patient is perceived as being foreign or alien, a stranger who either will not or cannot integrate himself into the community's values and expectations. One concept of returning the mentally ill to the community, was proposed in 1855; the author describes that system and also a system of foster care and other kinds of community care established in Illinois in the early 1940s. He emphasizes the need for a climate that accepts and is acceptable to chronic patients, and he discusses certain aspects of their care, including the problem that the so-called communities in which they are placed are communities in name only.

CINCE the introduction of the partial hospital into the spectrum of psychiatric treatment more than two decades ago, many programs oriented toward traditional inpatient and outpatient treatment have expanded to include partial care. The majority of partial hospital programs serve either as a transition between inpatient and outpatient care or as an alternative to inpatient treatment for selected patients. The use of such programs has been reported for many different types of patients, including the patient in acute crisis,’ the chronic patient,2 the alcoholic,3 the geriatric patient,4 and the emotionally disturbed child.5 We believe that the partial hospital may also be of value in the diagnosis and treatment of several additional groups of patients-namely, those for whom a court has ordered a psychiatric evaluation for either criminal or civil proceedings, nonvoluntary patients who may be committed to inpatient