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Ethics And Mental Health: Mental Disorder

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Discuss about the Ethics and Mental Health for Mental Disorder.




Deinstitutionalizing began in the1960’s when the people diagnosed with a developmental disability or mental disorder were placed in communities with mental health services rather than psychiatric hospitals [20,21,24]. Leon Eisenberg a renowned psychiatrist has said that deinstitutionalization has been beneficial for the mentally ill. This can be supported by a recent study done by Steven P. Segal, M.S.W., Ph.D., Stephania L. Hayes, M.A., O.T.R., Lachlan Rimes, B.A. under the title “The Utility of Outpatient Commitment 2. Mortality risk and protecting Health, Safety, and Quality of life”. In this study, Steven P. Segal along with his colleagues assessed the outpatient communities in Australia. They found out that there was a notable low mortality risk and the quality of life was enhanced in the case of the mentally ill in comparison to the psychiatric hospitals. As through this government policy, the mentally ill were able to move out of the “insane asylums” run by the government and were able to live in community health care centers. So according to the definition of deinstitutionalization,  it is not the reduction of the hospital censuses but it is the extension of the alternate services beyond a hospital setting. Although the closing of the psychiatric hospitals is the main part of this process it is only a part of the process. It is not all that deinstitutionalization stands for. Therefore this statement “Since the closure of mental institutions, the community has been over-run with dangerous people who do not get the care they need. Like it or not, they need to be kept separately from the rest of the community for everybody’s good” is neither completely false nor it is completely true in nature. Deinstitutionalization has had three components firstly it is the release of the mentally ill from psychiatric hospitals to communities with alternative facilities, secondly ensuring that new admissions are not made to these alternative facilities and thirdly provision of the care that these noninstitutionalized mentally ill need in these communities. Through these components, we can see that the last one is the most important. The altered life circumstances for these mentally ill will need new changes and configurations in the health services that they need. Therefore the statement made by the member of the parliament shows how he is fearful that our community is over-run by the mentally ill. But what it is pointing out clearly is that these mentally ill are not getting the care they deserve in these alternate services. It is showing how the government has failed to provide the care that these people need in a community care setting. [11]



Throughout the world, the process of deinstitutionalization has been given mixed reviews. In order to understand deinstitutionalization, we need to see what scientific and societal changes led to this process [17].Firstly the scientific discoveries of many psychiatric drugs helped to treat the mentally ill. Secondly, which is quietly debatable even now, the society understood that the mentally ill do not need to be locked but should be treated for their illness. Thirdly federal funding with programs like Medicare and Medicaid were sourced for community health centers for the mentally ill rather than psychiatric hospitals. It must be understood that the first and the second component of deinstitutionalization which are release of the mentally ill from psychiatric hospitals to communities with alternative facilities, secondly it is ensuring that new admissions are not made to these alternative facilities did rapidly proceeded than the third component which is provision of the care that these noninstitutionalized mentally ill need in these communities. The President of the American Psychiatric Association Dr. John A. Talbott who states how the psychiatrists that were involved in the formation of the policies related to deinstitutionalization, oversold the certainty of the community treatment which at present is hurting the credibility of this process. The widespread scientific discoveries in the 50’s and 60’s including penicillin to treat psychosis led to the leaders in being prodded to take action in believing that mental illness is far more prevalent in the society than it was first thought. This is completely true that mental illness is prevalent in our society in far more numbers than it was believed earlier. But the degree and symptoms of each mental illness vary greatly. While depression and anxiety are also termed as mental illness PTSD or Post Traumatic stress disorder is also a form of mental illness that may have violent episodes. The growing political and economic liability that the legislators were facing due to the taxes being used to support the mental institutions was a final push for deinstitutionalization. The extravagant claims that were made by the psychiatrists for the community health care centers for the mentally ill, only added to the urgency to create it. The scientific professional community has had made a mistake of being overly optimistic and the political community was all about saving money. The statement “Tranquilizers became Panacea” for the mentally ill is quite apt for this change.


The rationale to pursue deinstitutionalization had elements of pragmatism and idealism that reflect the concern for the wellbeing of the mentally challenged and ill. Many assumptions were made for the community based mental health care as for how this will be more humane than the psychiatric hospital care. This has proved to be quite true as studies such as “The Utility of Outpatient Commitment 2. Mortality risk and protecting Health, Safety, and Quality of life” conducted by Steven P. Segal, M.S.W., Ph.D., Stephania L. Hayes, M.A., O.T.R., Lachlan Rimes, B.A show [18]. But these assumptions had to be empirically tested as they cannot be realized until the severally mentally ill are included in the data pool. How will we realize whether they are being given the adequate and mandatory resources that are needed to implement these services? Secondly, it was assumed that the community-based health care centers will prove to be cost-effective in comparison to the psychiatric hospitals. Now has been seen that there are numerous hidden costs associated with these community-based health centers that were firstly ignored. It is crucial that not all of the psychiatric hospitals are closed as it is important to acknowledge that these alternative services require a structural overhaul to ensure that they are providing comprehensive and intensive care in a setting that is not like a psychiatric hospital. When the three components of deinstitutionalization are concurrently implemented it can result in being beneficial for the mentally ill. As the quality of care for these people is improved substantially and they experience a greater satisfaction in their everyday life. They obtain a certain “normality” in their life even after suffering from these illnesses. They are able to live independently to a certain degree and are numerous times are employed in the society thus making them productive to the society. But these positive developments cannot be applied to all mentally ill individuals. The severely mentally ill these “new” long-term community dwellings could be extremely challenging to sustain on their own. Numerous individuals will get easy access to drugs and alcohol which can make the conditions worse for their recovery and symptoms. There are concerns about the severely mentally ill who would have access to the community and society after living for many years in the psychiatric hospitals. Let’s take the example of people who suffer from bipolar disorder, major depression, schizophrenia and schizophrenia disorder. These people have been in hospitals for long and are passive to a point where they are used to following orders. In a community setting these people have sufficient structure and support to tend and cater to their needs. They have their sanctuary.[22]

It is not always that these mentally ill people are rehabilitated peacefully in the community. That is where the problem arises and the statement like these “Since the closure of mental institutions, the community has been over-run with dangerous people who do not get the care they need. Like it or not, they need to be kept separately from the rest of the community for everybody’s good” is made [4,6]. Many of these individuals pose new challenges to the clinicians and planners as they suffer from side effects of psychoactive drugs such as denial, and fear of tardive dyskinesia [14]. In a state of denial, a mental patient is skeptical about his or her treatment. Mentally ill are also admitted to the criminal justice system but due to deinstitutionalization number of these people are in the society. So when these circumstances along with a shortage of resources are mixed it results in shunting of the mentally ill. The society already has a low tolerance for the mentally ill as we have seen cases where even minor offence by mentally ill have resulted in arrest and incarceration. Many of these offence are often the results of manifestations of their illness. Through deinstitutionalization, we have developed a heightened awareness for the mentally ill. We want to be more humane and understanding towards them. Mental illness varies in a great degree and so is their ability to handle unpredictability and stress. Therefore the kind of programs that would help them varies according to their needs. These needs could range from either living alone, needing psychiatric interventions, would be better in living in a residential setting or less invasive care. Whether they would be able to work also depend on the degree of their illness. [19]


The service planners have grouped the mentally ill as a one, asking a single question “What should be done for the mentally ill?”. The focus is on individual need and rehabilitation or should we rephrase this question as “what should be done for this person who is suffering from a mental illness?”. It is crucial to understand that some of the mentally ill need the hospital care and deinstitutionalization is not a replacement for the care some need. Deinstitutionalization was introduced to eliminate the countertherapeutic practices that were being followed in the psychiatric hospitals but we do not need to eliminate these hospitals altogether. Unfortunately, the initial planning and implementation of these community centers were based on the assumption that we would no longer need any extensive resources for these mentally ill who need inpatient care. But experience has clearly shown that severely mentally ill need the hospital care for long periods of time and sometimes it could last their lifetime. The number of patients admitted to these hospitals precisely depends on the alternative services given in these facilities. So if these facilities have an array of integrated community based services and excellent infrastructure to support it tradeoffs are possible. Where the patients that are recovering well from their symptoms can be shifted to these facilities from the hospitals. For the success of deinstitutionalization we need to know that hospitals and these alternative services have to go hand in hand.

Mental health professionals have an ethical obligation to respond to the stigma and discrimination that the mentally ill face in our society [16]. If a member of the parliament will make statements like these the people would feel that mentally ill are dangerous for the society and should be locked. This mistreatment for the mentally ill strips them of the expectation and hope they need to recover from their illness [13]. In this essay, we have studied how deinstitutionalization is helping the mentally ill by giving them a better quality of life and giving them a certain degree of independence. Some are even working and adding as a productive member of the society. We even learned how all mentally ill cannot be grouped as one group. Therefore it is necessary that the mental health professionals educate the people and community about this. They need to educate people that a mentally ill person has equal rights for getting treated and to be treated with respect in the society. In a report by the NIMHE or the National Institute of Mental Health in England, it was stated that recovery for the mentally ill depends on many factors. Factors such as family support, community involvement, minimization of the stigma associated with their illness, clinical care, any meaningful activity or work and peer support. Many of these factors are community-based. These interventions need the support of the community. Counselors and educators are needed in the community to minimize the discrimination that the mentally ill face [3]. Approaches to the assertive community treatment where a team of multidisciplinary professionals work in a community setting for the recovery of a severely mentally ill (SMI) are needed [7]. Through these approaches and models, we can ensure that the mentally ill will be treated fairly in the community and would have lower chances of going homeless or be involved in a crime. Other models such as peer support model and supportive employment model are also found effective in many studies. These models are also helpful as the cost of providing care for a mentally ill decreases if he or she has recovered well enough to work. The health workers working in these community settings need specific training to work with SMI population. The movement of care from a hospital setting to a community settings needs specific training that these individuals should go through and ensure that the community around them supports the recovery process of a SMI. [10]

Many of the mental health professionals are obliged to learn about the cultural aspect of the care a SMI needs. The services have to be culturally relevant. These services should be planned according to both the rural and urban community settings. This is not only needed because of the variations in the community settings in these areas but also on the fact that the social support varies in these areas. Mental health professionals should aim to involved an SMI in their recovery process [23]. Each and every individual has a set of values and goals it is necessary that a health professionals realize this and be informed about these individual’s personal goals. The phrase “Ask the Patient” works well here. Consulting their family and friends is an extension for this care.



Mental health issues are often co-occurring with chronic physical problems. Therefore it Is needed that mental health care is integrated into community and primary based care. Through this essay, we have learned that community mental health is more therapeutic and humane than a hospital setting. But its full potential can only be realized when certain preconditions and factors are met. Due to these unmet factors, people fear the mentally ill. Which in turn encourages them to make statements like the one the member of the parliament made. That statement highlighted the fact that there are shortcomings in the care for the mentally ill in community settings on the part of the government and planners. There is too little knowledge in the community about the SMI. There are disjunctions in the following of the three factors or components of deinstitutionalization that are depopulation from the hospitals, diverting new admissions in the alternative services and development of the community-based services. We need to realize that the central problem is not locking the severe mentally ill in psychiatric wards but the central problem is provided adequate treatment and care to these individuals in a community-based setting. With the help of the psychosocial treatments and antipsychotic drugs, we can treat these individuals in an open community setting like apartments, halfway houses and care homes [8]. Nevertheless we do need to realize that there are a minority of some severely and chronically mentally ill persons that need the structured care of a psychiatric hospital. These people have to have a twenty-four hour specialized structured care and therefore we cannot eliminate mental health institutions from our society. We must aim for a continuity of support and care in the community [9]. Where the continuity of care is most important and these individuals need to be tended to in early years of deinstitutionalization. This is also the time where they can be monitored and seen whether they are fitting in the community setting or not. The lack of funding in training the health professionals have led to the failure of denationalization to a great level. Therefore additional funding along with educating the society about the mentally ill will help in achieving the success we need with deinstitutionalization. We have to highlight the plight of these victimized and isolated percentage of our population. They need the support and care of the community that can give them a life of satisfaction [2]. They should not be fear as dangerous and should not be subjected to harassment and stigma. When the mentally ill are unsupported only then they are at high risk to others and first and foremost to themselves. They should not be given a choice to trade the isolation they face in a hospital ward to the life of isolation they would face in an apartment or care house.



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