Discussion
Four different meanings of how 'institutionalization' in psychiatry is conceptualized were identified from sixty-one papers across eleven different countries, i.e. bricks and mortar of care institutions, policy and legal frameworks regulating care, clinical responsibility and paternalism in clinician-patient relationships, and patients' adaptive behavior to institutionalized care. These four identified connotations of how the term has been used in literature are conceptually distinct, but appear to overlap. Seventeen papers contained more than one of the four themes which may illustrate the complexity of the concept of institutionalization.
The conceptualization of institutionalization in psychiatry appears to have changed over time along with the changes in the provision of mental health care. Prior to the movement of deinstitutionalization, old-style mental hospitals functioned merely as a custodial care model and thus the perspective of bricks and mortar prevailed. The term 'deinstitutionalization' describes the process of downsizing and closing large hospitals accompanied by the establishment of alternative community-based mental health services.[76–77] As a result of the process of deinstitutionalization, many long-term hospitalized patients then were discharged into the community. It was found that the discharged patients experienced a higher quality of life compared to the hospitalized patients. Examples for such research are the studies of the Team for the Assessment of Psychiatric Services (TAPS) in North London[78] and the Berlin De-Institutionalization study.[79] Discharged patients reported better satisfaction with their living conditions and had acquired friends and confidants. In addition, they gained domestic and community living skills, although no change was found in the patients' clinical state or in their problems of social behavior. In modern psychiatry, however, the term 'institutionalization' goes beyond bricks and mortar as the functions of mental hospitals have changed. While in modern psychiatric hospitals less emphasis is put on institutionalizing patients with bricks and mortar, institutionalization is rather displayed in terms of policy and legal framework, in terms of clinical responsibility and paternalism or understood as patients' response to institutional care. Although institutional organization and clinical responsibility aim to provide a structured and safe environment to facilitate the treatment process and to help monitor patients, they can also unintentionally institutionalize patients. Clinical paternalism can reinforce patients' dependency on services, for instance, in the case of mandatory relationships between staff and patients where staff offer clinical paternalism- with the best intentions- to help patients manage their symptoms and life. Patients' mental capacity to consent to treatment may also have to be considered in this context, but has so far received little attention in the literature on psychiatric institutionalization.
If paternalistic relationships between staff and patients reflect institutionalization, then institutionalization must not necessarily occur in a physical facility such as a mental hospital, but patients may also be subjected to being institutionalized in supported housing or supervised residential facilities with around the clock staffing as well as other alternative institutions in community settings (i.e. forensic hospitals). In addition, if institutionalization is conceptualized as patients' response or adaptive behavior to services, then specialized community care such as assertive outreach could also be seen as a form of institutionalization due to the limited patient autonomy and their dependency on the intensive comprehensive care. Mental health patients residing in highly structured environments of community-based sheltered-care facilities can exhibit a distinct pattern of dependency.[80] Assertive Outreach (AO) has already been criticized for being paternalistic and coercive.[44] Service users of AO teams live, work and socialize in the community as "free individuals" yet they remain subject to rules and restrictions as if contained in old fashioned asylums.[18] Furthermore, patients who are legally mandated to receive treatment such as compulsory treatment in hospital or community might also be at risk of being institutionalized even though some argue involuntary psychiatric care helps to reduce symptoms, manage illness and re-establish a person's ability to make autonomous decisions.
In conclusion, despite modern psychiatric services continuing to reflect the trend of deinstitutionalization with the closure of large mental hospitals, reduction of psychiatric hospital beds and the discharge of long-stay hospitalized patients into community, the findings of this review suggest that institutionalization can still manifest in alternative forms of community-based institutional settings. Therefore, there is a risk that mental health patients might also be subjected to new forms of institutionalization in community-based services, as conceptualized in the four identified themes. Although the establishment of community care aimed to promote patients' autonomy and to provide care and treatment on a 'partnership and consensual basis' as much as possible, this review shows that institutionalization can still manifest in modern psychiatry similar to the old -style mental hospitals (asylums) beyond the traditional bricks and mortar hospital settings.[81–82] While patients may prefer community-based care to institutional ones, there is still a risk of subjecting mental health patients to institutionalization on psychiatric acute wards in general hospitals or new forms of residential facilities in community settings.
The results of this review can be related to critiques of Goffman's notion of the mental institution[20,37,83,84] namely that the earlier conceptualizations of institutionalization are limiting and can no longer be applicable in today's context. The traditional conceptualization of institutionalization reinforces mainly a restrictive understanding of institutionalization as taking place in institutions, where patients are only the sufferers of the treatment process and have limited autonomy and are completely isolated from the outside world. Townsend[82] concluded in his review that studies from 1959 to 1975 support the idea that institutionalization involves patients accepting institutional life and developing a lack of desire to leave after a long stay in mental institutions. More recently, Quirk and his associates[20–56] found that 'permeable institutions' provide a better representation of the reality of everyday life in modern 'bricks and mortar' psychiatric institutions.
Strengths and Limitations
One of the strengths of the review is that it considered literature from different disciplines and countries. Several main databases in the field were searched with broad search terms to avoid missing any major debates or discussions in the literature. In addition, the study team's expertise in psychiatry, psychology and public health were utilized to identify patterns, combine related subject matters and minimize potential biases.
The review also has a number of limitations. Since the aim of this review is to search widely, relevant articles may have been missed but also literature that does not contain the search terms of this review explicitly. Also, conference presentations or grey literature were not included. The replicability of the review is limited given that establishing what information is relevant was based mainly on the individuals who are conducting the review. Finally, due to the focus of this review on the field of psychiatry, it has been beyond its scope to appraise how the term institutionalization is used in other disciplines. Consequently, a wide body of literature in the social sciences such as those examining the institutionalization of inmates, juvenile offenders or children in institutional care has been excluded.
BMC Psychiatry. 2013;13(169) © 2013 BioMed Central, Ltd.
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