This include health promotion and prevention of illness and injuries, school health services, health centres, child health care provided by health visitors, midwives and general practitioner services, support for families, home nursing and home help services, long term services for the elderly, and day-centres for training and work. These public welfare services are part of the 'practical assistance' that covers all kinds of help for the performance of daily-life tasks in households with persons in need of such help.
This was also to include services to mental patients. From the responsibility for providing general somatic nursing homes was also transferred to the local councils. The PNHs were, however, still the responsibility of the counties.
During the late s and the s, specialised psychiatric services did not have first priority. Focus was on expanding primary care service, for instance for old people in nursing homes, home based care etc. In the psychiatric services focus was on giving active treatment. The counties, then, was cutting down on long time care services, while the local councils were still ill equipped to take over the responsibility.
From the early s, the role of the PNHs had been under discussion. In The Directorate of health published a report recommending that psychiatric nursing homes should be transformed to Living and Treatment Centres , later renamed District Psychiatric Centres DPC [ 40 ]. The DPCs should provide short-time inpatient care, day-centres and outpatient services for the local community, quite the opposite of what the PNHs had offered. Fewer patients than before had a psychiatric institution as their permanent residence.
By there were beds in the DPCs. In the following years they expanded rapidly, to beds in figure 5. By then they outnumbered the PNHs beds. The total number of beds was reduced by 31 percent from to The average inpatient population was correspondingly reduced.
The number of discharges, however, increased by 56 percent from to In the same period, the average length of stay was reduced from to 68 days.
The DPCs played a major role in increasing the number of discharges. In 'other institutions' including the DPCs accounted for discharges, 13 percent of the total. By , the DPCs alone accounted for , 20 percent of the total. During this period there was also a major increase in the outpatient services. In , the government published a White Paper [ 41 ] dealing with mental health issues. The services were characterized in this way: 'Patients do not feel they get what they need; staff do not feel they do a good job, and the authorities are not able to give the population satisfactory services.
The White Paper further concluded: a Primary prevention is too weak. The White Paper called for a major expansion and restructuring of services, both in primary care and in the specialised mental health services.
The Parliament ordered the Government to present a binding plan for improved mental health services. The following year a national mental health program was approved by the parliament [ 42 ]. Over the next eight years , later extended to running costs for the specialised services were to expand by 29 percent 2. A similar amount was set aside for improving services provided by the local councils, for instance sheltered housing [ 24 ].
District Psychiatric Centres DPCs should provide less specialised services on a more decentralised level. Psychiatrists and psychologists in private practice should provide services in co-operation with other mental health services. In addition, there was to be a major expansion of primary care services provided by the local councils. The number of beds was to increase considerably in DPCs and slightly in the hospitals.
Other institutions, mainly PNHs, should gradually be closed down. The total number of beds was, however, not to be reduced. The number of beds in DPCs increased by 25 percent from to figure 5. The number of beds in hospitals was, however, reduced by 13 percent. The PNHs were closed down at a much faster rate than planned and phased out by Despite the guidelines laid down in the program, the total number of beds was reduced by 21 percent from to figure 5.
The average number of inpatients was correspondingly reduced, see figure 1. The average length of stay was reduced from 66 to 31 days figure 4. The number of discharges grew by 63 percent, see figure 2. The increase was most pronounced outside the hospitals i. From to the average length of stay in these institutions combined was reduced from to 32 days, and the number of discharges was more than doubled. This section will focus on four topics: 1 General trends in the period studied.
The total number beds and the average number of inpatients increased up to the early s and have been reduced ever since. Throughout the period there has been a continuous reduction in the average length of stay. In addition, the average length of stay has been reduced significantly in the PHs from the mids and the PNHs from the early s. Despite reduced bed capacity, the number of patients treated in institutions has, with the exception of a short period during the s, continuously increased.
This means improved accessibility to treatment and care for the population. To characterize the period as a period of de-institutionalisation does not mean that fewer people than before is treated and cared for in the psychiatric institutions. The opposite is actually the case. The discharge rate has doubled from to Adding patients receiving out-patient treatment, the rate of inhabitants treated and nursed by the specialist mental health services increased even more.
We therefore underline that de-institutionalisation in Norway during the period means reduction in the number of beds and in inpatient population, not in the number of patients treated, neither in institutions in total nor in psychiatric hospitals.
There has been a reduced threshold for being referred and admitted to the mental health services and the mental health services have become more diversified. From the s out-patient clinics were founded in urban areas and about 80 District Psychiatric Centres has been established since Most patients are now treated and cared for outside the institutions, at out-patient clinics or in the municipalities. This indicates a shift in the focus of the services, from long-term care in private households and hospitals, to active treatment in smaller institutions and rehabilitation, after-care and nursing in the community.
Adding out-patient services, the increase have been even greater. During the whole period there has been a redistribution of beds and patients. Up to the mids psychiatric hospitals and private care were the dominant forms of care. From the early s until the mids there was a major expansion of the PNHs, relieving the PHs and private care of long term patients.
The PNHs has been closed down after being the institution with the highest inpatient population in the mids The period to is therefore characterised by institutionalisation, de- institutionalisation as well as trans- institutionalisation and in the following we give an account in more detail of the redistribution of patients in different periods. During the the mental health services have experienced periods of institutionalisation, de-institutionalisation, trans-institutionalisation as well as re-institutionalisation.
De-institutionalisation and trans-institutionalisation have been simultaneous processes. When analysing the redistribution of institutionalised patients in the period we also have to separate between de-institutionalisation and de-hospitalisation. It was not a period of de-institutionalisation, since the average inpatient population increased, private care excluded.
With the drop in the average length of stay in PHs and the expansion of GHDs, the number of patients treated increased even more. The PNHs had taken over the PHs former role as an institution for custody and care more than treatment. The 'de-institutionalisation' started as de-hospitalization in the early s. From to , the inpatient population at the PHs was halved. The average inpatient population in PNHs was stabilized and was not noticeably reduced until 15 years later; from the end of s.
The de-hospitalisation was at the same time a trans-institutionalisation since so-called chronic psychiatric patients were transferred from PHs to PNHs. The psychiatric nursing homes were often situated in remote rural areas and in institutions which were initially built for patients suffering from tuberculosis. Thus, what may look like de-institutionalisation in fact constitutes a trans-institutionalization and does obviously not correspond with modern ideas of mental health services.
By the end of the s, the PNH was the dominant mode of care. From then on, the inpatient population of the PHNs started to decline, and by the early s, most of these institutions had been closed down.
Some of the PNHs were either converted into, or replaced by DPCs, providing active inpatient as well as outpatient treatment to the local community. In one sense, this might be seen as a form of trans-institutionalisation. In another sense, then, the DPCs might be seen as the institutionalisation of new, community based services to new groups of patients.
The "rise and fall" of the psychiatric nursing homes during the period illustrates an era in the mental health services when professionals, authorities, relatives and patients believed in institutionalised long term care without treatment.
Nursing could more efficiently take place in large institutions; some of them build for other patient groups. These buildings were filled with psychiatric patients in need of nursing.
The rise the PNHs also illustrates trans-institutionalisation as well as a changing division of labour within the mental health services, between more active treatment at the PHs, while long term care was to be the responsibility of the PNHs.
These institutions played an important role in the mental health services in Norway for about 40 years. By the late s, after about 30 years of existence, they had become the dominant mode of mental care, taking care of more than 50 percent of the average number of inpatients. Since then, the focus of the mental health services has turned away from long term care, and the PNHs have been closed down. De-institutionalisation consists according to Bachrach [ 2 ] of three components, one of them are 'the development of special community-based programmes, combining psychiatric and supportive services, for the care of non institutionalised patient population.
De-hospitalisation in Norway started as a trans-institutionalisation, from PH to PNH and at that time, in the s, there were few community-based programs. Mental health services were still exclusively specialised institutional psychiatry. From the late the community based primary care in the local counties were gradually established as well as the out-patient clinics.
This introduced a new era of mental health services, given priority in the National mental health program - Different explanations can be given for the de-institutionalisation, re-institutionalisation and trans-institutionalisation. The need for institutional care in the s and s may have risen due to the loss of social support for people with severe psychiatric disorders in traditional families.
Urbanisation made the situation more difficult for families to take care of a patient and this was enhanced when women entered the labour market, taking professional roles instead of being domestic carers.
Assistance from the public health services became necessary, and total institutionalisation was the only option offered. The alteration of the services the last 60 years was affected by organisational changes, professional knowledge, and political-administrative intervention.
In the period there have been major administrative and political reforms in the health services in general. Increased awareness and emphasis has also been placed on the patients' own preferences and requests.
In the following, we will discuss the relevance of some common explanations for the de-institutionalisation of the services. The first anti-psychotic drugs were introduced in the early s. It has therefore been suggested that the new drugs made living outside the hospitals possible for many patients, and thus caused the de-institutionalisation, or more precisely: de-hospitalisation.
This description of the development in Britain and the United States from the mids do not fit the situation in Norway at that time. In Norway the introduction of the anti-psychotic drugs in the s did not lead to an immediate or strong reduction in the number of beds or the average number of inpatients in psychiatric hospitals, nor in psychiatric institutions in general.
On the contrary, the number of beds in PHs increased and the average number of inpatients was fairly stable until the late s. Neither was alternative settings outside the institutions and in the communities established until the s. Both inside and outside the services a view criticising the ill effects of prolonged stay within the large institutions emerged with increasing force during the s [ 29 ].
Sociologists and professionals argued that the 'total institution' maintained or created dependency, passivity, exclusion and disability, causing people to be institutionalized for a long time, even for the rest of their lives [ 27 , 28 , 30 ]. Three different, yet internationally influential theoretical positions, have been widely associated with the support for de-institutionalisation, and at the same representing the anti-psychiatric movement: Erving Goffman's Asylum [ 27 ], Michel Foucault's Madness and Civilisation [ 44 ] and Thomas Szasz's The Myth of Mental Illness [ 45 ].
These traditions were also present in Norway, but the anti-psychiatric movement has never been very strong, and was not a main reason for downsizing the psychiatric hospitals and institutions. Mechanic and Rochefort have pointed out that development of general public welfare services have influenced the de-institutionalisation of mental health services in two ways.
The development of social security programs disability pensions, public housing etc. On the other hand, the development of the welfare state was accompanied by a critique of the standard of living in the institutions, and demands for improvement that would lead to increased costs for inpatient services [ 10 ] see also [ 17 ].
In Norway, a universal disability pension plan was introduced in [ 46 ], later incorporated into the Law on Universal Social Welfare Insurance Folketrygden [ 47 ], which was passed by the parliament in The general welfare state system, disability pensions, old age pensions, unemployment payments, public housing, and universal health insurance were a major prerequisites for the smooth process of de-institutionalization in Norway, and made it possible for people with mental disorders to be cared for outside the institutions and in their own home.
Patients and their relatives also wanted more frequently to have an impact on the type and location of the services. It became more attractive, and more realistic, to provide community-based services rather than hospital based services.
Whether services became cheaper to decision-makers is debatable. Given budgetary constraints, most governments will try to minimize, or at least contain costs. The reduction in the inpatient population from the mids coincides with the depression following the oil crisis. Cost containment was also a stated purpose of the White paper and the financial reform.
The central government co-payment per inpatient days was replaced by a fixed central government grant to each county, based on the relative need for services. The economic incentives for keeping patients in institutions was in this way removed. In the period not only did the number of beds in PHs continue to decline, even the total number of inpatients treated per year also fell. At least in this period, de-institutionalisation might therefore be considered a means of cost reduction, or at least cost containment.
There is, however, little evidence that the costs were actually reduced. According to Statistics Norway the number of man-years in the mental services remained fairly stable from , despite the reduced number of inpatients [ 48 , 49 ]. In addition, the reduction in the average number of inpatients has also continued in periods of growing resources, although on a slower pace.
Since , there has been a major increase in the number of man-years, despite continuous reductions in the average number of inpatients [ 50 ]. During the National mental health plan , the number of beds has been reduced by 20 percent, despite the stated goal that the number of beds should remain stable. As we have seen, the average length of stay declined throughout the period. In general, short stays in institutions will require more man-power per inpatient day than longer stays.
At best, then, de-institutionalisation has facilitated increased focus on active inpatient and out-patient treatment, and has not been a means of cost reductions. Busfield [ 3 ] sees de-institutionalisation first and foremost as the result of a changing focus of services, from long-term care to acute treatment of patients with less serious problems.
Several factors have contributed to this shift: New medical ideas undermined the support for the traditional institutions, development of alternative services made it possible to live outside of the institutions, the psychiatrist wanted to be better integrated into specialised medical services in general, and increased therapeutic optimism suggested that shorter stays were possible.
The experiences from Norway support this hypothesis. As we have seen, there has been a continuous increase in the number of patients being treated, and a continuous reduction in the number of beds and the average length of stay in institutions. The primary care reform, giving the local councils formal responsibility for most primary care services, including services to people with mental problems, and closer integration of mental health services and general hospital services both support increased focus on active treatment and less emphasis on long term care.
Over the last decades increased emphasis has been placed on patients' own views and preferences. Through the national mental health program, this has also become public policy. The programme strongly emphasis that users of services are to be involved in the planning of services, both on the individual level and on the organisational level [ 42 ]. Surveys among inpatients at the mental health institutions in Norway have revealed that many patients preferred not to stay in the PHs or in other large institutions, but to live in their own home or in a sheltered accommodation, being supported by the mental health services [ 52 — 57 ].
The staff at the institutions also indicated that the ideal settings for many institutionalised patients would be community care or that patients at hospitals should be transferred to other and smaller institutions. Even in , approximately 30 percent of the inpatients would, according to the staff, be better off if treated and cared for in the community [ 58 ].
Obviously, one of the main criteria for judging a health service system is to what extent it provides the population with good, efficient services. The question, then, is to what extent patients have benefited from the changes taking place over the period. For patients in the hospitals this represented a reduction in the overcrowding and hopefully in the standard of living for the patients.
The movement of chronic patients from large PHs to smaller, more residentially like PNHs had probably the same effect. The move of patients from private care to PNHs might also have increased the patients' standard of living.
At least, that was the stated goal. The de-institutionalisation of services gained momentum from the mid, with the down-sizing of the PHs. Several surveys of in-patients conducted since the late s have indicated that many patients would prefer services in the community rather than in the institutions.
Likewise, according to staff, many patients would be better off; receiving community based services rather than staying on in a psychiatric institution. The question, then, is to what extent community based services became available.
There are clear indications that this was not the case during the first years of de-institutionalisation. Long-term patients were discharged before alternative community based services were available. This problem was accentuated by institutional barriers. The counties were responsible for the psychiatric institutions; while the local councils were responsible for most community based services.
There was a need for the planning of services based on patients' needs, not administrative and institutional boundaries, as well as better integration of services. In order to achieve this, the central government provided ear-marked grants. To get these grants, counties and local councils had to make plans for the development of services, and these plans had to be approved by government agencies.
Evaluation studies from recent years have documented that the recent alterations, especially the National Programme initiated in , has had a positive impact on access and equity, quality and efficacy, fairness, patients rights, protection, participation and treatment outcome [ 24 , 43 , 50 , 59 ]. The closing down of the large institutions, build for custody more than treatment, has been to the benefit of the institutionalized patients and the priority given to outpatient treatment has been an advantages to patients able to live in their own home.
The services in Norway are characterized bye more diversity throughout the whole period. This also means that the treatment and care has to a larger extent become more tailored for every person in need of treatment or care. The many smaller institutions established around in the local communities and with responsibility for a target area, the DPSs, with some beds and with outpatient service, are more in accordance with the patients' preferences and also with what psychiatrists and psychologists think is appropriate.
It has also improved the accessibility to the services for everybody. The Act of Patients' Rights from and the establishment of a Patient Ombudsman has improved patients' privileges and legal rights in general, for instance the right of access to the medical records and to chose where to be treated.
Any person, a patient or a relative, may contact the Patient Ombudsman and request that a case be taken up for consideration. In a recent comparison of USA, Great Britain, Canada and Norway, Norway was unique among the four countries in its vision of integrated mental health services grounded with equal accessibility for everybody [ 60 ]. It is said in this international comparison of mental health systems that other countries can learn from Norway.
The Norwegians adopted centralized financing and administration of mental health services to produce a more standardized and equitable system for delivering high quality care. Another lesson from Norway pertains to the vital role of workforce planning [ 24 ] without redistribution of personnel according to population density and prevalence rates, it is unlikely that a national policy authorizing universal access will be fully implemented or that the needs for mental health services will be met equitably, and especially in rural areas.
We have in this Paper traced changes in the inpatient care of Norwegian mental health services over the period Six distinct periods can be separated out:. Before The asylum period, characterised by long term care in overcrowded psychiatric hospitals and in private care.
Private care was gradually reduced. The average number of patients in institutions increased. The average length of stay in PH is more than halved. Disturbances of attachment in young children adopted from institutions. J Dev Behav Pediatr —6. PubMed Abstract Google Scholar. Merrill-Palmer Q , 54 3 — Tabassam W, Hamayun S.
Intelligence and personality differences among children from orphanages and intact families. J Indian Acad Appl Psychol 19 1—2 — Google Scholar. Cheyne WM, Jahoda G. Emotional sensitivity and intelligence in children from orphanages and normal homes. J Child Psychol Psychiatry — Behavior problems in postinstitutionalized internationally adopted children.
Dev Psychopathol — CBCL behavior problems of post-institutionalized international adoptees. Clin Child Fam Psychol Rev — Behavioural and emotional problems of children by type of out-of-home care in Croatia. Int J Soc Welf — Institutional rearing and psychiatric disorders in Romanian preschool children. Am J Psychiatry — Nilofer Farooqi Y, Intezar M.
Differences in self-esteem of orphan children and children living with their parents. J Raman Spectrosc 46 2. Forthcoming Orphan prevalence and extended family care in a peri-urban community in Zimbabwe. AIDS Care — Children, orphanages, and families: a summary of research to help guide faith-based action. Monasch R, Boerma TJ. Orphanhood and childcare patterns in sub-Saharan Africa: an analysis of national surveys from 40 countries.
AIDS — Child Care Health Dev — Save The Children. Keeping children out of harmful institutions: why we should be investing in family-based care. London, UK: Save the Children Browne K. The risk of harm to young children in institutional care. National Commission for Children. Ending the institutionalisation of children in Rwanda—the time is now. Child welfare outcomes for youth in care as a result of parental death or parental incarceration.
Child Abuse Negl — Dowdney L. Annotation: childhood bereavement following parental death. Soc Sci Med — Black D. The bereaved child. Depression in children and adolescents two months after the death of a parent. J Affect Disord — Psychological symptomatology following parental death in a predominantly minority sample of children and adolescents.
J Clin Child Psychol — Loss of parent in childhood and adult psychiatric disorder: the role of lack of adequate parental care. Psychol Med — Andersson G. Children in residential and foster care—a Swedish example.
Family relations, adjustment and well-being in a longitudinal study of children in care. Child Fam Soc Work — Barth RP.
Residential care: from here to eternity. Residential care: an effective response to out-of-home children and young people? Child Fam Soc Work 19 3 — Child Youth Serv Rev —5.
Behrendt A, Mbaye SM. The psychosocial impact of parental loss and orphan hood in Cameroon. Cameroun McInerney-Ernst EM. Adjustment outcomes following paternal loss among adolescents. Kansas, MA: University of Missouri 93 pages. Psychological well-being of orphans in Dar El Salaam, Tanzania. Seaton CL. Psychological adjustment. Encycl Posit Psychol — Zraly M, Nyirazinyoye L.
Structure and etiology of co-occurring internalizing and externalizing disorders in adolescents. J Abnorm Child Psychol — Liu J. Childhood externalizing behavior: theory and implications. J Child Adolesc Psychiatr Nurs — Coopersmith S. Coopersmith Self-Esteem Inventories: manual, instrument sample. Johnson MM, Rhodes R. Institutionalization: a theory of human behavior and the social environment. Adv Soc Work — Nemeroff C. The preeminent role of early untoward experience on vulnerability to major psychiatric disorders: the nature—nurture controversy revisited and soon to be resolved.
Mol Psychiatry —8. The fifth integrated household living survey EICV5. Achenbach T, Rescorla L. Burlington, VT: University of Vermont. Res Cent Child Youth Fam Keil V, Price JM. Externalizing behavior disorders in child welfare settings: definition, prevalence, and implications for assessment and treatment. Child Youth Serv Rev — Kokenes B. A factor analytic study of the Coopersmith Self-Esteem Inventory.
Adolescence The Coopersmith Self-Esteem inventory: a construct validation study. Educ Psychol Meas — Youngleson ML. The need to affiliate and self-esteem in institutionalized children.
J Pers Soc Psychol —6. Parental death and the adjustment of school-age children. Omega — Understanding contextual effects on externalizing behaviors in children in out-of-home care: influence of workers and foster families. Study of behavioral and emotional problems among institutionalized children.
Med J Cairo Univ 78 2 —9. Sekol I. Bullying in adolescent residential care: the influence of the physical and social residential care environment. Child Youth Care Forum 45 3 — Fight, flight, and freeze: threat sensitivity and emotion dysregulation in survivors of chronic childhood maltreatment. Personal Individ Differ — Severe punishment of children by staff in Romanian placement centers for school-aged children: effects of child and institutional characteristics. Agnew R. A revised strain theory of delinquency.
Soc Forces — Salivary cortisol levels in children adopted from Romanian orphanages. The dynamics of internalizing and externalizing comorbidity across the early school years. Predicting internalizing problems in Chinese children: the unique and interactive effects of parenting and child temperament.
Hazell P. Depression in children. BMJ — Internalizing disorders in early childhood: a review of depressive and anxiety disorders. Stanger C, Lewis M. Agreement among parents, teachers, and children on internalizing and externalizing behavior problems. Institutional care for young children: review of literature and policy implications.
Soc Issues Policy Rev — Depressive symptoms in youth heads of household in Rwanda: correlates and implications for intervention. Arch Pediatr Adolesc Med — Barriers to the community support of orphans and vulnerable youth in Rwanda. A propensity-score matching approach in Ghana. Designing research to study the effects of institutionalization on brain and behavioral development: the Bucharest Early Intervention Project. Case study in ethics of research: the Bucharest Early Intervention Project.
J Nerv Ment Dis J Youth Adolesc National Survey of Institutions for Children in Rwanda. Children in institutional care: delayed development and resilience.
Attar-Schwartz S. Emotional, behavioral and social problems among Israeli children in residential care: a multi-level analysis. A strict authoritative demeanor ruled throughout, for this was the approach of the time. Therapy and food were forced and there was zero tolerance for cry babies. None of us questioned, complained, or challenged our circumstances at the time. This was the norm, yet I can still recall the feelings of warmth and security when back with my family and the later anxiety and confusion when my parents were told about a "lovely home for children like me beside the sea.
I knew I still "belonged" to my family. They had no intention of seeing me separated again. Others were not so lucky. They grew up in institutions where parents could not visit and were not involved. Many adults, institutionalized as children or adolescents, now share stories both heart wrenching and horrific. The impact of being removed from your family, seemingly forever, without really understanding why, of living apart in a building labelled a "Children's Hospital" or "Home for Incurables", of having significant life altering medical and surgical procedures done without real understanding, involvement, or consent, of having little or no real opportunity to learn community living skills and develop meaningful relationships within the "real" world cannot ever be truly measured.
During my past 30 years as a rehabilitation professional, I have been involved in issues of institutionalization, both as a participant in facilitating placement, as well as in assisting institutionalized people with limited physical and experiential skills to move back into the community. I've also advocated with others in the community to establish viable community alternatives to institutionalization, such as Support Service Living Units, Outreach attendant programs, and Ontario's Direct Individualized Funding program for the provision of attendant support.
I've heard many times, first hand accounts of what happens when people lose their personal power and autonomy within institutional structures. I've seen the vacant, hopeless faces of those who live within. As a young student on the threshold of my career, my first encounter with institutional management of people was during a class visit to Kingston's Penitentiary for Women, followed soon thereafter by visits to Rideau Regional, near Ottawa, and Huronia Regional Centre for "the retarded", in Orillia.
The realization that humans have power over other humans, putting them away and controlling their basic human needs and freedoms, troubled me for weeks. The realization that many "inmates" were obviously intelligent and capable, but locked into bodies and systems which did not allow their abilities to be expressed, made me angry and afraid. The spectacle of hundreds of excited thronging humans eager for individual attention stayed with me.
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