deinstitutionalization

Let me start by saying that I realize I'm touching on a controversial subject.  I'm going to talk about it anyway.  

A few nights ago I was at a meeting about disability rights legislation.  Yay advocacy and policy development!  Anyway, at the end, for the "check out" (gotta love meetings run by social workers...) we had to share a barrier we thought was faced by the disabled community or that we were currently facing.  I talked about lack of adequate access to mental health care, some people talked about attitudes, others about accessability and employment, all the normal things.  What surprised me, was the number of people who talked about institutionalization and how important it was that we continue with deinstitutionalization.  

I'm not sure why it surprised me.  It's not exactly an unfamiliar concept for me, and for that matter it is something our government is currently working on.  Our newest Assertive Community Treatment team was set up to take referrals only from the long term mental health care facility, at least in it's initial stages.  In otherwords, it was designed to be intensive support for deinsitutionalization.  

The thing is, in my experience, institutionalization, in some way, is necessary, until we come up with better options for psychiatric treatment.  I spent eight months doing practicum in Assertive Community Treatment, the most intensive form of community mental health care my province has to offer.  The clients have a team of professionals and twenty four hour on call support.  They have daily contact, sometimes twice daily, observed meds and assistance with just about anything you could need assistance with.  Unfortunately, even with this very intensive level of support it was necessary to make two referrals to the long term care facility during my eight months.  Of course during that time we had many success stories as well.  

See the thing is, despite everything the team was doing, these clients simply could not be maintained in the community.  One woman was living in a rodent infested house with rotting floors, sleeping in a urine soaked bed, the house was in and out with drug dealers and the dirt was incredible.  She absolutely refused to take meds or to move.  Eventually the police had to remove her from the home and the public trustee made the decision to stop paying her rent.  The last time I saw her, she was doing okay in hospital, but certainly not well enough to live out again.  Another was so mentally ill and so drug addicted she jumped off a bridge, thankfully not too high up.  The courts didn't know what to do with her many crimminal charges and once release from jail or hospital she'd disappear for days at a time without taking her meds.  Because of her spinal injuries, she was referred to long term for her own safety.  

And then there are the forensic patients.  We have a special locked ward for them.  And seriously, I've been on the "worst" ward in the long term care facility.  The patients there are very, very mentally ill.  They are affected in ways that I cannot even begin to imagine.  Maybe with time, and patience and new treatments something will change, but until then... where will they go if their insitution is shut down?  

Finally there are the geriatric patients.  I've got news for you, schizophrenia doesn't end with middle adult hood, brain injuries don't magically heal.  And while we do have specialized homecare services, some clients just need more then that.  

So, i do agree with deinsitutionalization.  I want to be very clear about that.  I also don't agree with the institutions of the past, however, I want to make it very clear that there is a time and place in which long term psychiatric care facilities are necessary, and I don't think closing them all, especially without replacing them, will do the community a whole lot of good.