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Relocations, dislocations and innovations in mental health reform: examining the impact of psychiatric deinstitutionalization on women, men and communities.

Over the past three decades, developments in the understanding and treatment of mental health problems and broader social and economic trends have shaped the restructuring of the Canadian health care system. A key feature of mental health reform has been the deinstitutionalization of people with serious forms of mental illness from large psychiatric hospitals to various kinds of facilities, including more home-like tertiary care facilities and other forms of supported housing in the community.

In British Columbia, the most recent phase of deinstitutionalization began in 2000 and has involved both the restructuring of the province's only tertiary psychiatric facility, Riverview Hospital, and the transfer of people from the Lower Mainland to different facilities throughout the province. In BC's regionalized health care delivery system, in which resources are following individuals from a large urban centre to smaller communities, this phase of deinstitutionalization is likely to place new demands on mental health services in these communities, provide increased job opportunities in the mental health sector and generate greater interaction between community residents and people diagnosed with serious mental illnesses. Despite these changes and pressures it is expected that new models of residential care will enhance quality of life for people with serious psychiatric problems. To date, however, little is known about the ways in which deinstitutionalization might affect men and women differently and what kind of unique needs arise when people are relocated to new communities. (1)

Traditionally, it was assumed that the later onset of mental illness in women, better pre-morbid functioning, shorter hospital stays during periods of illness and wider networks of social support favoured women's residential independence, (2) as did women's greater skills for maintaining a household and fulfilling family roles. (3) However, although initially mentally ill women often do better than men in independent living situations, research suggests that these benefits are not necessarily sustained over time. (4) Research also shows that social variables play an important role in mental illness, most notably the fact that mental illness is exacerbated by lack of income security and social support. (5)

The Challenges of Fitting In

Divergent viewpoints about the causes and treatment of mental illness, combined with stigmatizing misperceptions about mental illness, may threaten the ability of new people to integrate into towns where populations are small and traditions of acceptable social behaviour are entrenched. (6) A recent study from Australia found that even six years after deinstitutionalization, issues of social integration remain. (7) Other studies have also demonstrated the need for sustained strategies for public education and opportunities for integration. (8) In fact, among deinstitutionalized residents, the attitudes of the community towards them and towards mental illness in general have been identified as priority problems. (9)

The deinstitutionalization of people with mental illness raises a myriad of other integration issues, including increased stresses on community-based organizations and voluntary caregiving labour that is often provided by female family members. Consumer advocacy organizations also feel stress when care is transferred to communities because mental health service recipients often require complex forms of advocacy when they live in communities. In addition, appropriate housing is probably the crucial community support service needed to achieve success of community-based care for people with mental illness. (10) A recent study using grounded theory demonstrates the interaction between the quality of housing for persons with mental illness and the quality of their relationships, which in turn relates to the level of social support they experience. (11) Although various studies have begun to demonstrate improvements for people with mental illness through the process of deinstitutionalization, all have found that it is contingent on the provision of a broad range of adequate resources. (12)

If deinstitutionalization is to be successful, the full range of people involved has to be engaged in it, especially people diagnosed with mental illness. Thus, mechanisms are needed to promote community involvement and the meaningful participation of the individuals being transferred from Riverview Hospital. Documenting the myriad views and experiences of people involved with deinstitutionalization and recognizing their differing degrees of personal and institutionalized power is thus critical to building community capacity in the reform process. (13)

There are few studies investigating the outcomes of deinstitutionalization in the Canadian context and those that have been conducted focus mainly on its clinical and/or professional and bureaucratic dimensions. This study is unique in its attention to the range of people involved in deinstitutionalization (mental health care providers, recipients, family members, and community members) to the institutional relations that shape mental health reform, its gender-based analysis, and its focus on the impact of deinstitutionalization on women and men with mental illness and the communities in which they live.


(1.) A new three-year study led by Dr. Marina Morrow (Faculty of Health Sciences, SFU) is investigating the capacity of communities to manage these changes and to provide for the specific needs of women and men leaving Riverview. "Community Capacity, Gender and Mental Health Reform in BC" will use feminist ethnography and a gender-based analysis to examine the process of psychiatric deinstitutionalization as it is unfolding in two towns in BC's interior health region (Kamloops and Vernon) and its impact on care recipients, family caregivers, care providers and communities. Dr. Morrow's research team includes Alain Lesage, MD, FRCPC (Centre de recherche Fernand-Seguin Louis- H. Lafontaine Hospital in Montreal, Quebec), Ann Pederson, MSc (BC Centre of Excellence for Women's Health), Jules Smith, MA, RCC (Senior researcher and field coordinator, SFU) and Lupin Battersby, MA, RCC (Researcher, SFU). The study is funded by the Social Sciences and Humanities Research Council and the Michael Smith Foundation for Health Research.

(2.) Test MA, Burke S, Wallisch L. Gender differences of young adults with schizophrenic disorders in community care. Schizophrenia Bulletin 1990;16(2):331- 44. Bennett M, Handel M, Pearsall D. Behavioural Differences between Female and Male Hospitalized Chronically Mentally Ill Patients. In Bachrach L, Nadelson C (Eds.). Treating Chronically Mentally Ill Women. Washington, DC: American Psychiatric Press, 1988;31-43. Angermeyer M, Kuhn L, Goldstein J. Gender and the course of schizophrenia: Differences in treated outcomes. Schizophrenia Bulletin 1990;16(2):293-318.

(3.) Test et al, 1990. McPherson H. The Impact of Severe Mental Illness on a Woman. In Romans SE (Ed.). Folding Back the Shadows: A Perspective on Women's Mental Health. Dunedin, NZ: University of Otago Press, 1998;251-61.

(4.) Cook J. Independent community living among women with severe mental illness: A comparison with outcomes among men. Journal of Mental Health Administration 1994;21(4):361-73.

(5.) Onken S, et al. Mental Health Recovery: What Helps and What Hinders? A National Research Project for the Development of Recovery Facilitating System Performance Indicators. Washington, DC: National Technical Assistance Center for State Mental Health Planning, 2002.

(6.) Halseth G. Cottage Country in Transition: A Social Geography of Change and Contention in the Rural-Recreational Countryside. Montreal: McGill-Queen's University Press, 1998. Sullivan LM. The geography of community crisis: A case of Tumbler Ridge, British Columbia [master's thesis]. Prince George: University of Northern British Columbia, 2002.

(7.) Hobbs C, et al. Deinstitutionalization for long-term mental illness: A six-year evaluation. Australian and New Zealand Journal of Psychiatry 2002;36(1):60-66.

(8.) Granerud A, Severinsson E. The new neighbor: Experiences of living next door to people suffering from long-term mental illness. International Journal of Mental Health Nursing 2003;12(1):3-10. Newton L, et al. Moving out and moving on: Some ethnographic observations of deinstitutionalization in an Australian community. Psychiatric Rehabilitation Journal 2001;25(2):152- 62.

(9.) Browne G, Courtney M. Housing, social support and people with schizophrenia: A grounded theory study. Issues in Mental Health Nursing 2005;26(3):311-26.

(10.) Browne, Courtney, 2005. Freeman A, Malone J, Hunt GE. A statewide survey of high-support services for people with chronic mental illness: Assessment of needs for care, level of functioning and satisfaction. Australian and New Zealand Journal of Psychiatry 2004;38(10):811-18. Hickie IB, et al. Australian mental health reform: Time for real outcomes. Medical Journal of Australia 2005;182(8):401-6. Holmes AC, et al. Accommodation history and continuity of care in patients with psychosis. Australian and New Zealand Journal of Psychiatry 2005;39(3):175-79.

(11.) Browne, Courtney, 2005.

(12.) Farhall J, et al. Minimizing adverse effects on patients of involuntary relocation from long-stay wards to community residences. Psychiatric Services 2003;54(7):1022-27. Leff J, Trieman N. Long-stay patients discharged from psychiatric hospitals. Social and clinical outcomes after five years in the community. The TAPS Project 46. British Journal of Psychiatry 2000;176:217-23. Lerman P, Apgar DH, Jordan T. Longitudinal changes in adaptive behaviors of movers and stayers: Findings from a controlled research design. Mental Retardation 2005;43(1):25-42. Sealy P, Whitehead PC. Forty years of deinstitutionalization of psychiatric services in Canada: An empirical assessment. Canadian Journal of Psychiatry 2004;49(4):249-57.

(13.) Morrow M. Mental health reform, economic globalization and the practice of citizenship. Canadian Journal of Community Mental Health 2004;23(2):39-50.

Marina Morrow, Faculty of Health Sciences, Simon Fraser University; Jules Smith, Reproductive Mental Health Program, BC Women's Hospital and Health Centre and Simon Fraser University; Ann Pederson, British Columbia Centre of Excellence for Women's Health; Lupin Battersby, British Columbia Centre of Excellence for Women's Health and Simon Fraser University; Alain Lesage, Department of Psychiatry, University of Montreal
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Author:Morrow, Marina; Smith, Jules; Pederson, Ann; Battersby, Lupin; Lesage, Alain
Publication:Research Bulletin
Geographic Code:1CANA
Date:Mar 22, 2006
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