From psychiatric hospitals to community services: a fifty years perspective - Julian Leff
Julian Leff*
Abstract
The progress of deinstitutionalisation will be reviewed from the mid twentieth century to the present day. In the US, the UK and other European countries the strategies employed to phase out psychiatric hospitals differ markedly. In Italy a law was passed prohibiting admission to psychiatric hospitals, whereas Finland operated a balanced policy of discharging long-stay patients while supporting family carers of people with psychiatric disorders.
The transformation of psychiatric services in high-income countries has been reasonably successful in improving the quality of life of previously long-stay patients. However problems have arisen with the admission wards in general hospitals. These stem from a failure to recognise that long-stay patients resettled in the community still require hospital admission at times. Furthermore, the inadequacy of community facilities in many places has led to the accumulation of new long-stay patients on the admission wards, reducing the number of available beds for acutely ill patients.
In middle-income and low-income countries large sections of the population have no access to biomedical psychiatric treatment. The low number of trained psychiatric personnel and inadequate primary care facilities mean that traditional practitioners are the only resource available to patients and their family carers. In most low-income countries the development of a comprehensive network of community psychiatric services has a very low priority compared with the provision of clean water and housing, containing the AIDS epidemic, and alleviating poverty.
Even in the twenty-first century many patients with serious psychiatric illnesses are looked after in psychiatric hospitals in poor conditions with no legal protection of their rights. Governments can learn from the successes and failures of the deinstitutionalisation programmes in high-income countries how best to provide humane conditions for the care of people with serious psychiatric conditions.
Key words: deinstitutionalisation; long-stay patients; community psychiatric services.
Rezumat: Vor fi trecute în revistă progresele înregistrate de dezinstituţionalizare începând cu mijlocul secolului douăzeci şi până în prezent. In Statele Unite, Marea Britanie şi alte ţări europene, strategiile folosite pentru a elimina treptat spitale de psihiatrie diferă semnificativ. În Italia, a fost adoptată o lege care interzice internarea în spitalele de psihiatrie, în timp ce Finlanda a aplicat o politică echilibrată de externare a pacienţilor cu spitalizări îndelungate, sprijinind în acelaşi timp îngrijirea în familie a persoanelor cu tulburări psihice.
În ţările cu venituri mari, transformarea spitalelor de psihiatrie a avut un succes rezonabil în îmbunătăţirea calităţii vieţii pacienţilor cu spitalizări anterioare îndelungate. Au apărut însă probleme în cazul internărilor în secţiile din spitalele generale. Acestea rezidă din incapacitatea de a recunoaştere a pacienţii cu internări îndelungate aflaţi în comunitate şi care necesită încă spitalizare. În plus, în multe locuri, caracterul inadecvat al facilităţilor comunitare, a condus la acumularea de pacienţi cronici în spitale reducând astfel numărul de paturi disponibile pentru pacienţii acuţi.
În ţările cu venituri medii şi mici, segmente mari ale populaţiei nu au acces la tratament psihiatric biomedical. Numărul redus de personal psihiatric specializat şi facilităţile de îngrijire primară necorespunzătoare fac din practicienii tradiţionali singurele resurse disponibile pentru pacienţi şi familiile acestora. În majoritatea ţărilor cu venituri mici dezvoltarea unei reţele cuprinzătoare de servicii psihiatrice comunitare are o prioritate fosrte scăzută comparativ cu furnizarea de apă curată şi locuinţe, limitarea epidemiei SIDA sau reducerea sărăciei.
Chiar şi în secolul douazeci şi unu mulţi pacienţi cu boli psihice grave, sunt îngrijiţi în spitale de psihiatrie, în condiţii precare, fără protecţia juridică a drepturilor lor.
Guvernele pot învăţa din succesele şi eşecurile programelor de dezinstituţionalizare din ţările cu venituri mari despre modul în care pot oferi condiţii umane pentru îngrijirea persoanelor cu afecţiuni psihice grave.
Cuvinte cheie: dezinstituţionalizare; pacienţilor cu spitalizări îndelungate; servicii psihiatrice comunitare.
__________________________
* Emeritus Professor, Institute of Psychiatry, Kings College London; De Crespigny Park, London SE5 8AF; Correspondence to Professor Julian Leff, 1 South Hill Park Gardens, London, NW3 2TD. Email j.leff@iop.kcl.ac.uk
Introduction
Psychiatric hospitals have a long history in high-income countries: for example, the Bethlem Hospital in London was founded in 1247 and continues to exist today. It is noteworthy that it began as a priory, to which the monks started to admit people with psychiatric illnesses in 1377. There are equivalents in low-income countries, such as Ethiopia, where the Coptic churches also offer shelter and treatment to psychiatrically ill people today, and probably have done so for many centuries. However in low- and middle-income countries the building of psychiatric hospitals, or asylums, as they were known in Victorian Britain, never approached the massive scale that was attained in countries such as the US and UK. So pervasive was this enterprise, and so proud were the Victorians of their achievement, that they reproduced their asylums in all parts of the British Empire, leaving countries like India with buildings that are instantly recognisable as clones of their UK equivalents. Even relatively small former British possessions, such as Bermuda and Trinidad, have one asylum built by the colonists. A surprising example is provided by Corfu, which was taken over as a protectorate in 1848 by the British, who built the first psychiatric hospital in Greece on this island. Of course these asylums were not intended for the native populations, but for the British civil administrators and soldiers who maintained British rule.
In low-income countries which have a few such asylums dating from the 19th century, the great majority of the population have no access to the psychiatric services provided. Instead they rely on traditional practitioners (TP) for the treatment of psychiatric illnesses. It should not be assumed that traditional treatments invariably involve chaining patients and beating them. A study of a TP found that although aggressive and overactive patients were chained, after they had been given extracts from the plant known as snakeroot (Rauwolfia), they settled down, the chains were removed after a maximum of two weeks and they were inducted into a programme of graded work around the compound, leading to agricultural tasks in the fields (1). We would readily recognise this as rehabilitation. Many TPs are astute individuals with great sensitivity to human relationships, and their treatments are aimed at reintegrating the patient into her/his social support network. Nevertheless, where biomedical psychiatric facilities are scarce or non-existent, the lack of access to antipsychotic medication condemns many patients and their family carers to a poor quality of life (2).
As a result of this dichotomy in the provision of psychiatric services between high-income countries and the rest of the world, the former have been faced with a task of much greater magnitude than the latter in attempting to transform the base of their services from psychiatric hospitals to the community. I will focus on this process in the US, the UK and some other European countries, before considering the issues facing the rest of the world.
TRANSFORMATION OF PSYCHIATRIC SERVICES IN THE US AND UK
In both these countries the reduction in psychiatric beds in the asylums began in the 1950s and continued throughout the century, resulting in the complete closure of many of these institutions. This transformation has proceeded further in the UK than the US, with the result that of the 130 psychiatric hospitals existing in England and Wales in 1975, only around a dozen are still open. Scotland has had a separate Department of Health for several decades and has pursued a different policy. Table 1 shows the expansion of psychiatric hospitals during the 19th and 20th centuries in England and Wales and the subsequent decline in their number.
Table 1.
Number of county asylums/psychiatric hospitals in England and Wales
1827 9
1850 24
1900 77
1975 130
2000 14
The beginning of deinstutionalisation, as it is called, is often ascribed to the introduction of chlorpromazine to psychiatric practice in 1955. It is true that psychiatric bed occupancy in England and Wales reached a peak of 148,000 in 1954 and declined to less than 20,000 by 1998. However in some pioneering hospitals the reduction in bed numbers began some years before 1954 and must be due to other factors. These have been identified as different in the US and the UK. In the UK the experience of psychiatrists in military hospitals during the Second World War convinced them that recovery from serious psychiatric illnesses induced by major stresses was a reality. In addition they discovered the value of treating the disturbed soldiers in groups. At the end of the war these psychiatrists entered the asylums and modified the custodial atmosphere with their new-found optimism, leading to the discharge of patients formerly considered incurable. In the US young men who refused to fight on the grounds of conscience were assigned to work in the asylums, whereas in the UK conscientious objectors were put to work in the coal mines. The young men with high moral values who entered the US asylums brought humane attitudes to the care of the patients, thereby ameliorating custodial practices.
The problem facing administrators of the asylums in both countries was the same: how to provide the full range of hospital services in a community setting. This had to include a place to live, rehabilitation to enable as many patients as possible to undertake work, provision for leisure activities, social support, and care for mental and physical health. All these requirements were provided in the intensely centralised psychiatric hospital, rendering it a total institution (3). Dispersal of the centralised service gave rise to many logistic problems, not all of which have been solved satisfactorily. Rehabilitation services epitomise these. For eight years I worked in Friern Hospital in North London. Opened in 1851 for one thousand patients, by 1950 the number of beds had increased to almost 2,500, resulting in great overcrowding. The number of patients diminished steadily from 1954, so that when I moved to the hospital in 1980 there were about 800 patients left. Of these, 120 attended the industrial therapy unit daily. This unit provided a wide variety of work experience, from simple assembly of plastic components to highly skilled engineering tasks. One of the supervisors designed wooden furniture, including feeding tables for birds, which very popular sales items, many of which were purchased by members of staff as well as visitors to the hospital. There was also a horticultural section, which provided a stress-free environment with little time pressure.
During the planning process the possibility of dispersing the excellent rehabilitation service provided by Friern was considered. It became apparent that it would not be financially viable, since there would need to be a transport service that dropped off the components to be assembled to the different scattered locations, and then collected the finished products. The contracts with businesses that enabled the hospital service to run at a small profit, could not be fulfilled in time by the decentralised workshops. Nevertheless, a number of sheltered workshops were established in the communities in which the patients were resettled. As they moved out of the hospital another problem became evident. Many of them were reluctant to attend these workshops once they were no longer impelled by the nursing staff to walk from their wards to the unit, as was the practice in the hospital, but instead had to take public transport to reach their place of work. Furthermore, the average age of these patients was sixty, and they much preferred to visit a place where they could have a cup of tea or coffee and enjoy the company of other patients they knew. Consequently, some of the sheltered workshops were replaced by drop-in centres run by NGOs, which were appreciated by the patients.
In general the UK programmes provided reasonable accommodation for the discharged long-stay patients, mostly by buying houses and converting them to provide a number of single bedrooms. In the Friern reprovision, on average there were eight patients in each converted residence. This was in great contrast to the hospital wards which often housed 30 or 40 patients. Not all the UK programmes provided adequate accommodation. For a few years discharged patients were resettled in seaside boarding houses. This was a cheap solution because the boarding house keepers were glad to have residents all the year round instead of only being busy in the holiday season. However they turned the patients out during the day, and grim scenes of patients wandering along deserted windswept promenades during the winter created a public outcry. As a result this practice was halted and the patients relocated in more suitable residences.
Despite the concern expressed by the media and the public that deinstitutionalisation was leading to an increase in the numbers of homeless mentally ill people, studies in the UK showed that this was not the case (4). By contrast, homelessness did become a conspicuous problem on the streets of US cities during the 60s and 70s. The problem stemmed from the policy known as ‘Board and Care’. This gave the responsibility to private landlords to provide decent accommodation for discharged patients and some kind of care for their daily needs, in exchange for a weekly stipend. The large number of patients being discharged turned this commercial arrangement into Big Business, amounting to 16 billion dollars a year. So enticing was this that it attracted the interest of the Mafia (5). While much of the accommodation provided was acceptable, there were scandalous instances of grossly substandard housing. The ‘Care’ component was conspicuous by its absence, which was hardly surprising given that the landlords were given no training in the care of people with serious psychiatric disorders.
During the 1960s, Community Mental Health Centres (CMHCs) were established throughout the US, and were intended to provide support and services to psychiatric patients. While they were staffed by idealistic young people anxious to provide a good service, the staff lacked the experience to deal with the vested interests in their neighbourhoods which opposed the changes they were trying to introduce. The Community Mental Health movement was further weakened by President Nixon’s misappropriation of funds granted by the Senate for the CMHCs. With the rise of biological psychiatry during the 1970s and 80s, the CMH movement went into decline, except for a few islands of good practice kept going by enthusiastic entrepreneurs (6).
PROBLEMS WITH THE UK PROGRAMMES
The transformation of psychiatric services has probably been more comprehensive in England and Wales than in any other country in the world, partly due to the infrastructure provided by the National Health Service (NHS). Therefore it is instructive to examine the problems that arose there and discuss their origins. The long-stay patients and those with dementia enjoyed a better quality of life in their new community homes than they had in the psychiatric hospitals (7,8). However serious problems arose with the psychiatric admission wards in general hospitals. These were intended to replace the admission beds in the psychiatric hospitals, but the planners assumed that the number of replacement beds could be reduced. The evidence on which this decision was based is not clear, but probably financial considerations were foremost. In the event it soon became clear that insufficient admission beds were available, and as a consequence admission wards throughout England and Wales have been operating at 120% occupancy for many years now. This does not mean that patients are sleeping two to a bed: rather there is a heavy use of private hospital care for acutely ill psychiatric patients at a considerable cost to the NHS. In fact private psychiatric hospitals, many of them managed by American companies, have been expanding in the UK to meet the increase in referrals from the NHS.
The lack of foresight by the planners was due to a number of unrecognised demands in the transformed system. There was an assumption that once long-stay patients were resettled in their community homes, they would not need admission to psychiatric wards. This proved to be false. The study of Friern and Claybury hospitals by the Team for the Assessment of Psychiatric Services (TAPS) found that at any point in time one in ten discharged long-stay patients was occupying a psychiatric hospital bed. So that for every hundred long-stay patients discharged, ten hospital beds were needed (9). Another issue not taken into account by the planners was those patients admitted to psychiatric wards who stayed longer than three months. In the psychiatric hospitals such patients were moved to rehabilitation wards, or to the ‘back wards’ if there was pessimism about their prospects for recovery. This resource for clearing admission beds does not exist in the general hospital wards, and until recently few rehabilitation units had been established in the community. In addition to the previously discharged long-stay patients, other patients accumulating on the admission wards are young people with a recent onset psychiatric illness (10). These have been termed ‘the new long-stay’. This particular group became evident in the TAPS study due to the policy of the hospital management, which was to keep the admission wards open and active until the hospital closed. This has become known as a ‘back door policy’, since old long-stay patients were discharged by the back door while the front door was kept open for new admissions. The build-up of new long-stay patients in the two hospitals in the TAPS study increased the number of long-stay patients assessed from 670 in 1985 to 1166 by the time Friern hospital closed in 1997. It was noted that the number of such patients varied considerably according to the district from which they were admitted, and a strong correlation was found between socio-economic deprivation and the number of new long-stay patients (11). It is crucial to recognise that long-stay patients will continue to arise from the community after the closure of psychiatric hospitals, and their needs must be planned for in the new service.
OTHER EUROPEAN COUNTRIES
I will focus on three other European countries, Italy, Finland, and Greece, since they demonstrate very different approaches to deinstitutionalisation.
The Italian Experience
By contrast with the back door policy operated in England and Wales, Italy put into practice a front door policy. In 1978 the Italian Parliament passed Law 180, with strong support from the Communist Party. This law imposed a ban on building new mental hospitals and on admitting new patients to the existing ones, which had to be gradually phased out and used for other purposes. The law also endorses the principle that the prevention, treatment and rehabilitation of the mentally ill should normally be carried out in community services. In addition the law establishes the creation of Services or Stations for Psychiatric Diagnosis and Treatment within the General Hospitals, which can have a maximum of 15 beds each. This law effectively closed the front door of all state psychiatric hospitals.
At the forefront of the movement that agitated for this change was Franco Basaglia, a psychiatrist working in Trieste, who had already begun the transformation of the psychiatric hospital in that city. Many of the services in the north of Italy responded to the challenge represented by Law 180 and developed psychiatric admission facilities in general hospitals. The town of Arezzo in Tuscany was claimed to have created a model service. I visited their psychiatric facilities in the 1990s and was impressed with the progress made. They had established two psychiatric admission beds in a general hospital ward for patients with physical illnesses. I was surprised that they claimed to manage all acute psychiatric emergencies for a population of 100,000 with just these two beds. The answer to this puzzle came when I was taken to the community services. The central element of these was a team consisting of a psychiatrist and psychiatric nurses who were available 24 hours a day to deal with emergencies by visiting patients in their own homes. This facility effectively contained most psychiatric emergencies without the need for admission, but at the expense of a very heavy work load for the staff. At the time I considered it unlikely that such a service would be acceptable to staff in the UK. However, 24-hour treatment and assessment teams were promoted as a strategy by the UK Department of Health, which set out targets for 2004 and 2005 for the numbers of Crisis Resolution teams expected to be in place, and the numbers of home treatment episodes completed. Crisis teams are now widespread throughout the UK, although there are some conflicts with pre-existing community mental health teams over issues of responsibility for patients. They have also had the effect that the population of psychiatric admission wards in general hospitals has become dominated by very disturbed and aggressive patients, with whom the nursing staff find it difficult to cope.
Other support services I saw in Arezzo were pleasant sheltered flats for discharged long-stay patients, gardening teams composed of patients, who cared for the public gardens in the town, and a workshop where patients made wooden toys designed by a member of staff, which were sold in a shop in town run by patients. I left with a favourable impression of the psychiatric services, but the situation is very different in other regions of Italy, particularly the south, where progress has been sluggish. Furthermore, in some psychiatric hospitals I visited, to which no new patients were admitted, the old long-stay patients were living in poor conditions in neglected buildings, and little effort seemed to be made to resettle them in the community. In conclusion there are some excellent examples of well-functioning community services and some inspiring creative innovations, such as the Hotel Tritone in Trieste, which is totally run by patients, but over the whole country the picture is patchy.
Finland
In 1619 Gustav Adolph II of Sweden founded Finland’s first hospital of the Crown on the island of Seili. The hospital functioned first as a leprosarium and later as a psychiatric institution. A new hospital was designed and built from 1800-1803. The buildings that housed the patients contained rows of single cells 1.87m. by 2.07m. in size, and they formed a veritable prison where violent or agitated patients were kept in chains. People banished to Seili could never return; they had to live on the island until their death, after which they were buried in unnamed graves. As there were few trees on the island, patients arriving from the mainland travelled with the timber for their own coffin. The patients were sometimes grossly mistreated. Much of what really happened on the island is known through letters which were never delivered to their relatives on the mainland. The hospital was closed many years ago.
Despite this dark history, the most comprehensive approach to deinstitutionalisation in the world is probably that operating in Finland. Considerable planning effort has been directed at resettling long-stay patients in the community. In addition a carefully constructed programme has been developed to reduce the need to admit patients with a first onset of a psychiatric illness or a relapse. By contrast with the British Crisis Resolution teams, the Finnish programme includes interviews with the family and the patient together in order to help and support the relatives with their caring role. There is strong evidence for the value of working with the family when the patient suffers from schizophrenia (12) but relatively few services in western countries incorporate this crucial element in their programmes (13).
Greece
While several well-developed community services exist in Athens, in the past two decades psychiatry in Greece has been overshadowed by the scandal of the Island of Leros. There are many historical instances of people with psychiatric illnesses being banished to islands. As in Finland, the island of Leros was also dominated by a psychiatric hospital to which patients were sent from the mainland, never to return. Leros is eleven hours by ferry from Athens. It had previously been a naval base and then the buildings were used as a prison for political prisoners. In 1959 the use of the buildings changed to a psychiatric hospital. In 1995 a documentary showing the inhumane treatment of the patients was screened on British television and provoked an outcry. There were images of naked patients being washed with hoses in a courtyard and of the squalid cells in which they lived. The European Union (EU) made available to the Greek Government a substantial fund intended to be used to return patients to the mainland and improve conditions on Leros. A follow-up study was conducted of one hundred of these patients four years after their return to the mainland (14). They were resettled in 13 community hostels located throughout the mainland. They all had been institutionalised for many years, and most of them were socially deprived with few family ties. The majority of patients preferred their lives in the hostels to conditions on the island. Despite the encouraging outcome of this study, some years later very little had changed in the hospital itself. The EU appointed commissioners to oversee the process of reformation of the hospital and gradually the necessary changes were effected.
MEDIUM AND LOW-INCOME COUNTRIES
Here I will discuss the issues facing South Africa as typical of countries with few psychiatric hospitals and a large scattered rural population with scarce psychiatric facilities and personnel. I will also briefly refer to the situation in Romania.
South Africa
I have worked in South Africa on a temporary basis since 1980, mainly in Cape Town. For the population of 47 million there are 19 old psychiatric hospitals in South Africa, situated in or near the cities. Efforts have been made to discharge the long-stay patients, but many still remain due to lack of community facilities and the inability of impoverished families to care for them. There is a paucity of trained staff, particularly in the rural areas. Over the whole country there is only one psychiatrist for every 350,000 people, one psychologist for every 312,000, and one social worker for every 250,000. No community facilities to treat psychiatric illness exist in the North West and the Northern Cape. The government, emerging from the repressive Apartheid era, is faced with enormous problems of poverty, a disrupted education system, emigration of skilled white professionals, and an AIDS pandemic of horrifying proportions. Funding for the development of psychiatric services is of low priority. One strategy would be to integrate psychiatry into primary care services, as advocated by the World Health Organisation (15.), but these are also deficient, particularly in rural areas. Steinberg (16) recounts a visit he made in 2005 to a remote area of the country.
‘In a rural district in the Eastern Cape in South Africa, of the twelve clinics, two had reliable electricity supply, one had running water or a phone, and none a fax machine. Few of the medicines on South Africa’s essential drugs list had ever found their way to the district’s clinic shelves, and those that had were there only sporadically. Less than four in ten nursing posts were filled. Per capita, the district had fourteen times more people per doctor than the national average.’
South Africa’s dilemma of where to start the process of developing a comprehensive psychiatric service is common to most low- and middle-income countries. Closing the psychiatric hospitals without developing community facilities throws an intolerable burden on families and is likely to increase the population of homeless people with psychiatric illnesses. Putting in place the essential community services without tackling the problem of the old psychiatric hospitals leaves many long-stay patients in inhumane and degrading environments, which perpetuate the stigma of psychiatric illness. I have no comforting solution to offer. However some balance between the two options has to be found within the restrictions of the available funding. This is a matter for debate.
Romania
The Amnesty International Report on Romania this year continues to express concern about the care of children and young people with mental disabilities in institutions. The descriptions of the state of the inmates given in a recent report are reminiscent of the conditions on the island of Leros. These include inadequate or absent clothing, and poor nutrition and hygiene. Romania is not alone in Europe in needing to radically transform its psychiatric hospitals. Governments can learn from the successes and failures of the deinstitutionalisation programmes in high-income countries how best to provide humane conditions for the care of people with serious psychiatric conditions. Governments that, through neglect or design, allow people to live in inhumane institutional environments are sending a clear message to the public that people with psychiatric illnesses do not deserve to be treated as normal citizens. It is a message that reinforces the stigma that surrounds psychiatric illnesses throughout the world.
In July 2009 I attended the Central and Southeast European Regional Congress of Social and Community Psychiatry held in Gura Humorului. During the Congress I visited the psychiatric hospital in Campulung Moldovenesc, which provided an opportunity to appreciate the advances in the transformation of psychiatric services in Romania. The psychiatric inpatient service was originally located in the Town Hospital, which was opened in 1889. The psychiatric wards shared the building with the general medical and surgical wards. There were a number of disadvantages to this arrangement, stemming from the stigmatising attitudes of the non-psychiatric staff, including the management. It was not possible to employ psychologists or social workers, or to purchase medication, and low quality staff were sent from the general hospital to the psychiatric section. Such problems are not unique to Campulung, nor to Romania. I have visited general hospitals in low-income countries in which the psychiatric wards were deliberately sited away from the main building in an obscure part of the site and occupied poorly designed and maintained buildings. This needs to be seen in the context of government policy in the UK, which since 1959 stipulated that the admission wards in the old psychiatric hospitals should be transferred to general hospitals to counter the isolation of psychiatric patients and their professional staff. As the previous situation in Campulung exemplifies, this intended integration of psychiatry with general medical services does not always achieve its aims of reducing the stigma attached to psychiatric disorders.
The director of the psychiatric services in Campulung, Dr Alexandru Paziuc, took the bold step of separating the psychiatric services from the other specialties, a policy directly opposite to that advocated in the UK and many other western countries. The service he directs has been housed in a building of their own since July 1999, when the Minister of Health agreed to its sole use as a psychiatric hospital. In order to transform the service, Dr Paziuc created an independent management structure, enabling him to hire two psychologists, two social workers and two occupational therapists, and to replace almost half the original staff. In the subsequent ten years Dr Paziuc has succeeded in creating a high quality service. This comprises 80 inpatient beds, for a largely rural population of 300,000, a day hospital with 20 places, a room for group meetings including psychotherapy, its own patients’ records system, a pharmacy, laundry and kitchen, and excellent occupational therapy facilities. I visited these and was impressed with the quality of work in dressmaking, artwork, ceramics, weaving, knitting, and carpentry. The ground floor of the building has been refurbished to a high standard and provides a pleasant physical environment.
Dr Paziuc has also extended the service beyond the confines of the hospital by creating mobile teams that visit patients and their families in their homes throughout the extensive catchment area. He has also succeeded in obtaining the agreement of the local authority to develop a greenhouse on a vacant site in town, in which patients can be employed growing flowers and vegetables in a cooperative.
He works closely with an NGO which he was instrumental in establishing in Campulung Moldovenesc in 1995. Named Horizon, the NGO includes users, families and members of the community, and the mayor of the town is now a member and works actively on its behalf, facilitating the greenhouse project. Horizon not only takes measures to destigmatise psychiatric illnesses and improve the users’ quality of life, but is also active on behalf of the whole community. The progress that has been made in a decade in developing a community-oriented service is extremely impressive and should inspire colleagues throughout Romania to undertake similar changes to the existing psychiatric hospitals. Of course there is still a long way to go to create a comprehensive alternative to institutional care. The inclusion of users in the ordinary working environments is one target to aim for. Another is recognition of the crucial role of family carers in ensuring the well-being of users. I took the opportunity of my visit to Campulung hospital to run a half-day workshop for the staff on how to inform family members about psychiatric illness and on the ways of improving the emotional environment in the home, to the benefit of the users. I found the staff eager to learn and responsive to the new approach to which they were being exposed.
TRANSFORMING PSYCHIATRIC SERVICES:TEN AXIOMS
1. Would you want someone you love to be treated in any psychiatric hospital in your country?
2. Good community care is not less expensive than care in a psychiatric hospital.
3. All inpatient psychiatric care should be provided in general hospitals.
4. There are innovative services which can avoid the need for admission to a psychiatric ward.
5. Staff working in psychiatric hospitals will resist the transformation of their service and need re-education and re-training if they are to work in community services.
6. People with psychiatric illnesses need help with finding employment and establishing a supportive social network.
7. Families who look after a relative with a psychiatric illness must be informed, supported, and given guidance on care by professional staff.
8. Stigmatising attitudes of the general public can be reduced by local educational campaigns, focusing on neighbours and schoolchildren. National campaigns are very expensive and have little effect on stigma.
9. People with psychiatric illnesses need to be asked what they want from services and must be listened to.
10. The moral strength of a country is judged by its treatment of people with psychiatric illness.
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