Highs and lows of community psychiatry

In a perceptive article written 17 years ago, Sumathipala & Hanwella described what they called a spiral of community care. This was derived from evidence over a long time period that society alternates between embracing community psychiatry as an inclusive and positive way of treating the mentally ill, and an exclusive psychiatry at other times, when those with mental illness are perceived as dangerous or problematic in other ways and therefore detained in institutions of one sort or the other. I think this hypothesis has credence and, if you look around the world, you can find evidence of societies in which both the inclusive and exclusive models are being practised. For example, Japan in recent years has consistently practised the exclusion model. Most people with significant mental illness, particularly that which handicaps their ability to fit in with what is a well-ordered society, are placed in institutions. Many of these institutions are not mental hospitals, and some are quite benign in their practice, not least because many Japanese patients who have serious mental illness appear to accept this way of life without questioning or railing against it. Other societies, particularly those in low-income countries, have never been able to practise ‘exclusive psychiatry’ because they do not have the institutions to house those with severe mental illness. Where are we now in what we would like to consider are the more enlightened countries? The early gloss has gone off the excitement of community psychiatry and the focus has been more on excluding people from hospital than providing good community care. The general mantra of ‘community psychiatry good, hospital psychiatry bad’ has been a two-edged sword, for although it has promoted the development of many community psychiatric services, it has also led to the neglect of the proper function of in-patient care, a combination of asylum and rehabilitation, and today may have reached a point where a fundamental wish to improve patients’ autonomy is being removed by an overbureaucratised system of community care that is obsessed by risk, and in danger of promoting greater institutionalisation by a complex regulatory framework that denies the flexibility that is essential to good community psychiatric practice. As a consequence, patient autonomy has been reduced and involuntary admission rates have risen across Europe, leading to urgency in the need for a solution. Where in the UK community psychiatry used to be flexible, adventurous, creative and bold, with the many changes imposed from policy managers in recent years it has become constricted, controlled, limiting and self-serving. Autonomy for practitioners has almost entirely disappeared and been replaced by a rigid system of care that leads to patients encountering a bewildering number of health professionals, who carry out specific regimented tasks but who rarely have the chance to develop meaningful relationships with the people they treat. In the full flower of community psychiatry, perhaps best expressed in the 1975 government White Paper, Better Services for the Mentally Ill, there was no limit put on the extent to which community psychiatry might extend. The policy suffered through having no clear costings or time scales, but the intention was to gradually close down mental hospitals, improve the links between primary and secondary care, and practise what is nowadays called ‘localism’, developing treatment as much as possible in smaller areas where needs could be identified and staff could be The Psychiatrist (2013), 37, 336-339, doi: 10.1192/pb.bp.113.042937